Craving: Approaching Avoidance : Part 7

by National Institute of Health

(Page 7 of 7)

One perspective on cognitive conflict or ambivalence provides for the explicit definition and measurement of component dimensions, whereas conflict in Tiffany's cognitive processing model is inferred from the increased cognitive effort thought to be associated with the dual processing required when competing response inclinations are present. However, the two models are complementary in that Tiffany's distinction between the automatic processing associated with direct, unimpeded approach and the effortful processing associated with craving is also a distinction that differentiates the quadrants in the multidimensional, ambivalence model.

Preliminary laboratory evidence is pertinent here. Participants who simultaneously reported high levels of both approach and avoidance inclinations in connection with the viewing of appetizing food slides showed a significant increase in heart rate during slide viewing. Such an elevation of heart rate is consistent with the engagement of greater cognitive effort during the viewing of food slides. In contrast, participants who rated their reactions to the same slides as high in approach but low in avoidance showed a decrease in heart rate. This decrease in heart rate reflects simple orienting but no elaborative processing. Using similar picture-viewing protocols, comparable contrasts in heart rate responses were also found for restrained (ambivalent) eaters versus nonrestrained eaters in a combined sample. These data support the applicability of a multidimensional, ambivalence model to a wide range of addictive and habitual behavior problems.

Summary and Implications for Prevention and Intervention

This article began by noting that the traditional focus of alcohol research on craving as the force driving individuals down the path toward alcohol consumption fails to adequately account for the role of competing inclinations to avoid alcohol and not drink. A similar bias also exists in research on "historical" and dispositional risk factors as well as on situational or "current" factors relevant to choices about drinking. A brief review of recent research developments, especially in the areas of alcohol expectancies and drinking motives, has further revealed that avoidance inclinations associated with the pathway of restraint are potentially important determinants of the choices to drink or not drink. Within this context, evidence indicates that factors promoting avoidance inclinations appear to be better predictors of treatment outcome than factors promoting approach inclinations. Clearly, the full picture involves more than the stimulation of craving by cues that have been associated with drinking.

Reactions associated with alcohol cues are multifaceted and capable of interacting with a wide range of other factors to touch off parallel and potentially contradictory response chains that must be resolved. Recognition of these complexities and a shift toward simultaneous consideration of competing approach and avoidance inclinations are essential to a better understanding of craving and choices about drinking. A multidimensional, ambivalence model provides a framework for future investigations in this area as well as suggests avenues for prevention of drinking by young people and for the treatment of anyone who suffers from problem drinking.

Most prevention programs emphasize the adverse consequences of drinking and promote abstinence from all drinking, leaving children to wonder why anyone would drink or how they could drink moderately and responsibly under appropriate circumstances as adults. However, societal ambivalence about alcohol is liable to be reflected in the ambivalence many young people experience as they face the challenge of making responsible decisions about drinking. Evidence suggests that developmental shifts occur in the way children evaluate alcohol's positive and negative effects. For prevention strategies to be optimally effective, researchers need to understand how problem drinking does not develop and what produces protection against it. Utilizing a framework that accounts for the balance between approach and avoidance inclinations is an important step in that direction.

When considering interventions for people with drinking problems, every clinician knows that motivation is a vital element. Consequently, an initial and fundamental goal of contemporary motivational interviewing techniques is to provoke clients to recognize a "discrepancy" between their important personal goals and the harm stemming from their strong inclination to drink. By encouraging an assessment and weighing of the pros and cons of drinking versus not drinking, the aim is to strengthen a client's inclination to avoid alcohol relative to the inclination to approach it. In terms of the concept of an evaluative space, "discrepancy" has been achieved when a client moves from the approach quadrant into the ambivalence quadrant. When working with clients who experience addictive behavior problems, the application of an ambivalence model, with its two-dimensional evaluative space, has significant advantages over unidimensional assessments of craving. Clients who know that the strength of their inclination to not drink will also be measured seem more able to acknowledge their inclination to drink. This works to improve the validity of self-reports because it diminishes the demand to deny craving that is often so intense in clinical settings.

Furthermore, ambivalence can be a normal and important step toward increasing readiness and maintaining efforts to change. In fact, to the extent that clients struggle with strong inclinations to drink alcohol, ambivalence may be the only buffer between the resolve not to drink and relapse during the initial stages of treatment. In this connection, we wish to emphasize that ambivalence is associated with inaction, whereas drinking is a state of action. As long as ambivalence is maintained, lapses into drinking should be minimized. It also follows that fluctuations in the strength of avoidance inclinations may be better predictors of treatment outcome than the strength of approach inclinations, which often remain high and fairly constant, at least through the early phase of intervention. Tiffany has pointed out that craving alone is not necessary for substance use. However, according to a more integrative and comprehensive analysis, when craving occurs, it must be counterbalanced by avoidance inclinations that often demand intense cognitive effort to produce ambivalence if substance use is ultimately to be restrained.

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.