Craving: Approaching Avoidance

A Step Essential to the Understanding of Craving
by National Institute of Health

Craving is only one component of the mental processes that influence drinking behavior. Alcohol-related cues (ARCs) can set in motion a dynamic competition between inclinations to approach drinking and inclinations to avoid drinking. Craving can thus be integrated into a comprehensive model of decisionmaking in which ambivalence or conflict is a key element. The relative strength of each component of the ARC reaction can fluctuate over time as well as in response to both subjective states and environmental circumstances. Simultaneously and independently evaluating these opposing responses puts clinicians in a better position to influence the relative weight that the patient assigns to the positive and negative outcomes of alcohol consumption.

Most researchers and practitioners in the alcohol field agree that alcohol "craving," defined here as an inclination to approach and consume alcoholic beverages, is a critical feature of alcohol use disorders. Such craving may be activated by stimuli or "cues" that the patient has come to associate with reinforcement from drinking. However, an exclusive focus on the forces attracting a person toward alcohol consumption is arguably too restrictive and contrasts sharply with the thrust of many traditional treatment strategies, which tend to minimize consideration of the rewarding aspects of excessive drinking. Practitioners typically strive to foster abstinence or reduced drinking among problem drinkers by advocating avoidance and restraint. Accordingly, the transformation of alcohol-relevant cues into signals warning of impending punishment is a tactic often used by practitioners to emphasize the adverse consequences of drinking.

The goal of this article is to encourage both scientists and clinicians to appreciate the complexity of responses elicited by alcohol cues, particularly the likelihood that these cues can prompt a dynamic competition between inclinations to approach drinking and inclinations to avoid drinking. By simultaneously and independently evaluating these opposing responses, researchers and treatment professionals might understand the essentially unidimensional construct of craving better and integrate it into a comprehensive motivational model.

The concurrent operation of both approach and avoidance inclinations in people experiencing problems with alcohol and other addictive substances is not a new idea. Indeed, the significance of these competing motives is apparent in current diagnostic criteria for addiction (dependence) to alcohol or other drugs (AODs). These criteria include using the substance in larger amounts or over a longer period than was originally intended, along with a desire for the substance despite efforts to cut down or control its use. Based on these characteristics, AOD-dependent patients are seen as both drawn toward and repelled from substance use.

This observation has led a number of theorists to identify ambivalence or conflict as a key element of excessive appetites of many kinds. Thus, an adequate theory of alcohol use problems must explain not only why alcoholics return to drinking despite resolutions not to do so but also why they often succeed, either temporarily or permanently, in refraining from problem drinking. Heather has argued that addictive behavior is defined, at least in part, by ambivalence associated with the decisionmaking process. Intervention strategies consistent with this concept attempt to motivate recovery by influencing the relative weight the patient assigns to the positive and negative outcomes of alcohol consumption.

The theorized role of ambivalence in alcohol use disorders suggests that craving is only one component of a multidimensional phenomenon comprised of largely independent inclinations to approach and avoid drinking. This framework for understanding responses to alcohol-related cues assumes that the relative strength of each component of the reaction can fluctuate over time as well as in response to both subjective states and environmental circumstances. Such a conceptualization departs from the traditional view that craving alone drives decisions about drinking. However, it does incorporate mechanisms by which low-intensity, seemingly "irrelevant" stimuli, thoughts, and actions can set the stage for later inclinations to approach and consume alcohol. This article strives to integrate the concept of craving into a comprehensive model that better captures the reality of addicts' struggles along the dual pathways of indulgence and restraint. A recurrent theme is that responses to alcohol-relevant cues are multifaceted and dynamic.

Pathways to Indulgence and Restraint

Many modern motivational theories of alcohol use rest on the premise that problem drinking is mediated by the same decision processes that govern all alcohol use and that people essentially choose between drinking and alternative actions. According to this view, people decide whether to consume alcoholic beverages by comparing the positive consequences they expect to experience by drinking with those they expect from not drinking. The figure on page 198 illustrates the parallel nature of the pathways that promote either indulgence or restraint. This figure adds two features to a model proposed originally by Cox and Klinger: it incorporates a complementary perspective, based on behavioral theories of choice, which holds that preference for alcohol is inversely related to the accessibility of alternative valued activities, and more importantly, it incorporates an "evaluative space" to represent the intersection of the opposing pathways of approach and avoidance. Such ambivalent or conflicting inclinations appear to be central both to cognitiveprocessing theories of craving and to recent shifts in thinking about the essence of addiction in more general terms. The integration of a variety of competing factors and responses - both positive and negative - within a multidimensional evaluative space ultimately determines a person's choice to drink or not drink, thereby underscoring the potential importance of the evaluative space and emphasizing the need for an explicit assessment of the two independent dimensions.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.