Neurocognitive underpinnings of denial and decision making

Neurocognitive underpinnings of denial and decision making in treatment choice for drug addiction

Sarah St. Onge

Cognition James Nelson, PhD, Professor Derner Institute for Advanced Psychological Studies

Neurocognitive underpinnings of denial and decision making

Neurocognitive underpinnings of denial and decision making in treatment choice for drug addiction

Drug addiction is conceived as a cognitive disorder that shares similarities with neuropsychiatric and psychiatric disorders (such as schizophrenia). One notable similarity is impaired awareness. This impairment affects failure to recognize an illness, denial of illness, compromised control of action, and unawareness of social incompetence (p. 372). In addition, impaired self-awareness affects such basic daily functions as decision making. According to the results of a 2006 national survey on drug use and health (SAMHSA, 2007, as cited in Goldstein et al., 2009), 80% of addicted individuals failed to seek treatment because they were unaware of the severity of their illness. Added to these 21.1 million persons, are individuals who are aware of their illness, in treatment or remission. This results in an astronomical percentage of people in our nation suffering from substance abuse or struggling not to relapse. This reason alone behooves us to study the neurocognitive underpinnings of this disorder so that practitioners from related fields can work together to determine the most effective way to support and aid such individuals. NEUROCOGNITIVE FINDINGS

Neurocognitive underpinnings of denial and decision making

Three neuro-scientific studies offer significant and overlapping findings about the effect and interaction of denial among the affected brain regions of addiction. Goldstein and her colleagues (2009) place emphasis on the insula, anterior cingulate, and dorsal striatum regions found to be most related to interoception, insight and selfawareness. Bechara (2005) considers the conflicting impact of the dual systems of the amygdala and prefrontal cortex in affecting the cognitive resources needed to exercise willpower and impulse control in decision making. Verdejo-Garcia and Perez-Garcia suggest alterations in the frontostriatal systems, which play a critical role in selfawareness and denial.

Goldstein et al. (2009) Among the affected brain regions in addiction, the insula, anterior cingulate, and dorsal striatum regions are most related to interoception, insight and self-awareness. These concepts are needed to help us recognize and describe our own (and others) behaviors, cognitions and mental states (p. 372). Damage to any of these neural circuits affects other, related neural structures, resulting in dissociated, or dysfunctional behavior. As such, drug addiction can be viewed as a compromised ability to recognize external and internal drug-related cues (p. 373), resulting in excessive use, dysregulated control of use, and compromised self-awareness, often mislabeled denial. Clinical psychologists looking to the DSM-IV to guide decisions about a diagnosis of drug dependency, note that altered awareness is a major criterion. However, with denial in question as a valid marker of altered awareness, neuroimaging offers another

Neurocognitive underpinnings of denial and decision making example of what such a state looks like. Also, given the importance of self-awareness and interoception in understanding drug addiction and its treatment, practitioners need to have a better grounding in the abnormalities in the insula and medial regions of the prefrontal cortex (including the anterior cingulate and mesial orbitofrontal cortices) that underscore interoception and behavioral control. The insula The posteria insula in all primates contains interoceptive representation of the

physiological condition of the body. The anterior insula in humans integrates emotional activity from other forebrain regions for a re-representation of interoceptive responses, and is also related to emotional awareness, empathic feelings, and to cooperative social behavior. In determining the role that the insula plays in drug addiction, an interesting study on cigarette smoking was conducted by one of the authors (Bechara in Naqvi et al., 2007, cited in Goldstein et al., 2009). 19 smokers with sustained damage in the insula were compared with 50 smokers who sustained damage in other areas of the brain. Consistent with other research findings on the crucial role of the middle insula in cravings for food, cocaine and cigarettes, the insula-damaged smokers experienced a disruption in nicotine addiction as indicated in neuroimaging studies. The anterior cingulate cortex Similarly, reduced activity in the anterior cingulate cortex was associated with selective attention and inhibitory control for cocaine, heroin, alcohol, cannabis and other drug users. For example, in a study that compared cannabis users and non-users on a task of determining error awareness, imaging reported blunted rostral and dorsal

Neurocognitive underpinnings of denial and decision making anterior cingulate (and insula) response along with significant diminished awareness of errors in cannabis users. These studies predict, It is most likely that abnormalities in the insula contribute to intense drug cravings and compromised insight and awareness of disease severity, whereas abnormalities in the cingulate cortices contribute to the disadvantageous decision-making that precipitate relapse (p. 377). Additionally, the anterior cingulate cortex is implicated in conscious and

subjective experiences (such as pain and pleasure). The anterior cingulate and bilateral anterior insula work together for perceptual awareness of visual or auditory stimuli. Damage in these regions correlate with decreased emotional self-awareness and selfconscious behaviors, and affect decision-making abilities. Distinctive roles for the anterior insula and anterior cingulate cortices affect control over ones behavior. Together, the anterior insula and anterior cingulate cortices are conjointly activated in all human emotions and behaviors. The dorsal striatum Neural imaging results indicate that there is a switch that occurs from voluntary to automatic drug use involving movement from the prefrontal cortex to the dorsal striatum region of the brain, the site of dopaminergic reactions. This affects both drug-seeking and drug-taking behavior. In a study with rats (Miller & Cohen, 2001, cited in Goldstein et al., 2009), it was found that disconnecting the ventral-dorsal striatal loop greatly and selectively decreases habitual cocaine seeking (p. 377). This switch to an automatic and habitual system adds to an already compromised insight into the severity of ones addiction.

Neurocognitive underpinnings of denial and decision making Drug cues have been found to stimulate drug craving in the limbic reward circuitry of the brain. Imaging results indicate that, both cocaine and sexual unseen cues activated the ventral striatum/pallidum, amygdala, anterior insula, and caudolateral orbitofrontal cortex, paralleling prior studies of reward circuitry in humans and animals (Childress et al., 1999, cited in Goldstein et al., 2009). These findings suggest that drug-related stimuli outside of awareness affect brain motivational circuits but also point to possible treatment modalities that may rely on systematic desensitization efforts. Bechara (2005) Bechara noted that there are similarities between substances abusers and patients with damaged ventromedial prefrontal cortex (VMPC) areas of the brain. Both

have a tendency to deny, or are not aware that they have a problem. Specifically, it was noted that when faced with a choice that could result in an immediate pleasure response versus negative future consequences, the majority of both drug addicts and VMPC patents chose the more immediate, pleasure-seeking reward. This finding was substantiated in a study in which patients and addicts were taught the rules to a gambling game: the Iowa Gambling Task. Subjects were asked to choose between four decks of cards, each with a different potential payoff, to maximize their monetary gain. 63% of drug addicts performed within the range of patients with VMPC in choosing cards with immediate financial rewards despite increasing losses associated with those choices. Based on this finding, Bechara became interested in understanding the link between substance abuse, denial and decision making.

Neurocognitive underpinnings of denial and decision making

Bechara proposes that multiple brain mechanisms work together in addiction. He believes that addiction is a condition in which the neural mechanisms that enable one to choose according to long-term outcomes are weakened, thus leading to loss of willpower to resist drugs (p. 1). In fact, Bechara suggests that while we may see reduced decision-making as a result of addiction, it may well be that a weakened decision-making ability underlies the initial use and escalation of substance use leading to addiction. Somatic marker theory Bachara bases his research on a somatic marker hypothesis. Somatic markers are emotion-related signals, both body- and brain-related, that assist cognitive processes in implementing decisions. The somatic marker hypothesis is a systemslevel neuroanatomical and cognitive framework for choosing according to long-term, rather than short-term, outcomes (p. 1). The amygdala and VMPC are critical for triggering somatic states: The amygdala responds to events that occur in the environment; whereas the VMPC responds to events in memory, knowledge and cognition. Bacharas research indicates that willpower emerges from an interaction between the two neural systems in which the amygdala and VMPC reside: the impulsive system and the reflective system. The impulsive system The somatic marker theory links the features of the stimulus to its affective/emotional response. Physiological evidence suggests that powerful, shortlived affective responses occur in the amygdala, such as viewing or encountering an object of fear (e.g., a snake) or pleasure (e.g., money). Although money is not initially

Neurocognitive underpinnings of denial and decision making associated with affective properties, when its image is linked with drug use, it can become a powerful reward trigger in the impulsive system. Research has been

conducted that suggests that drug cues, such as pictures of a needle, can also produce strong, affective triggers in the amygdala-ventral striatum system. Like the Goldstein et al. study, this ascribes a functional role to the striatum in the motivational and behavioral aspects of drug seeking and addiction.

The reflective system The VMPC is a critical substrate in the neural system necessary for triggering affective states from recall or from imagination (Bechara, 2004, cited in Bechara, 2005). In the reflective system, affective reactions can also be generated from recall of personal or imagined affective/emotional events. One would think that recall of negative consequences of drug use (i.e. trouble with the law, bodily damage, loss of finances, family, job) would affect ones decision making process in future drug use; however, dysfunction in the VMPC causes a state of obliviousness that may lead to escalating use, and vulnerability to addiction. Other systems within the VMPC are also linked to critical processes in decision making. The dorsolateral sector of the prefrontal cortex and the hippocampus are linked to memory. Maintaining an active representation of memory over a delay of time involves the dorsolateral sector of the prefrontal cortex, and patients with damage to this structure show compromised decision making. Thus, decision making depends on memory as well as for emotion and affect.

Neurocognitive underpinnings of denial and decision making Cross-over effects Bechara claims that addiction is the product of an imbalance between these two separate, but interacting, neural systems that control decision-making. The control between the two is not absolute; but evidence suggests that hyperactivity within the impulsive system can override the reflective system. Drugs and drug cues can trigger bottom-up, involuntary signals originating from the amygdala to take over the goaldriven cognitive resources that are needed for the normal operation of the reflective system and for exercising the willpower to resist drugs. However, there are also topdown effects that mediate this finding.

Decision making deficits in addicts, and also in some of the normal controls in the study, are not uniform across all individuals. As opposed to the 63% of addicts who performed similarly to the VMPC patients, 27% did not. Bechara believes that there may be more than one mechanism by which the reflective system exerts control over the impulsive system. Besides decision making, there are other mechanisms of inhibitory control to be examined, such as the ability to inhibit the intrusion of unwanted information (such as thinking about drugs). Also, other neural regions of the prefrontal cortex still need to be examined to determine the saliency of their effects on addiction. Verdejo-Garcia & Perez-Garcia (2005) In a study examining self-awareness of cognitive deficits in drug addicts, Verdejo-Garcia & PerezGarcia state, Recent neuro-scientific evidence suggests that denial of problems related to drug use can be associated with alterations in the frontostriatal systems, which play a crucial role in executive functions and selfawareness (p. 172). This area also affects emotional regulation and motivation.

Neurocognitive underpinnings of denial and decision making Specifically, poor awareness of cognitive deficits during rehabilitation can be associated with reduced motivation towards reaching treatment goals, failure to use recommended compensatory strategies, and a greater feeling of control over risky behaviors, including those involving an actual encounter with the drug in the environment. (Rinn, 2002, cited in Verdejo-Garcia et al., 2004, p. 174).

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Study participants included a sample of 38 abstinent poly-substance abusers and their self-appointed informants in Granada, Spain. Informants were required to know the substance abusers well enough to report on their daily behavior patterns. All abusers were abstinent for a minimum of 15 days and had ended rehabilitation at the same time. No participant was taking any substance-related medication. Substance abusers and their informants were asked to complete the Frontal Systems Behavior Scale (FrSBe), a 46-item rating scale with 3 independent subscales for: apathy (poor initiation, loss of energy and interest, blunted affective expression), disinhibition (problems with inhibitory control, socially inappropriate behaviors, unmodulated or excessive emotional expression), and executive function (deficits in planning, working memory, mental flexibility). The FrSBe has high internal consistency and reliability, especially in detection of frontostriatal deficits in substance abusers. The standard version of the scale is intended to quantify behavioral change due to frontal lobe lesions. Abusers were assessed during drug use (they were asked to retrospectively rate their behavior during lifetime drug use) and during abstinence. Results indicated that informants scores were significantly higher than substance abusers scores on apathy and executive function during drug use, indicating poor awareness of deficits.

Neurocognitive underpinnings of denial and decision making No significant discrepancies between abusers and informants scores were noted

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during abstinence. Severity of alcohol and cocaine abuse significantly predicted poorer self-awareness during drug abuse, but not during abstinence. Based on the findings of this small study, researchers concluded that the frontostriatal systems play a critical role in supervisory and self-awareness processes in drug addiction. This is supported by previous observations about the similarities between substance abusers and patients with lesions in the orbitofrontal cortex, who also tend to present with poor awareness of their cognitive deficits. These results are also consistent with the previous studies of Goldstein et al. and Bechara whot have reported incidental and direct evidence of the relationship between cognitive deficits and denial or poor awareness in drug addicts. Although substance abusers reported relatively high levels of behavioral symptoms (especially of executive dysfunction) during drug use, discrepancy with informants scores may have relevant clinical implications. For example, reduced awareness about the actual degree of deficits might be closely associated with poor judgment and a variety of ill-considered choices during drug abuse, including sharing needles, risky sexual behavior, driving under the influence of drugs, and higher incidence of antisocial behavior. Furthermore, neurocognitive skills seem to modulate the response of high-risk populations to prevention materials. Thus, the findings could have important implications for prevention strategies, which should highlight the impact of drug abuse on self-awareness. These findings may also have important implications for motivational attitudes towards treatment, since substance abusers presenting poor

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awareness may be reluctant to acknowledge their addiction and to seek treatment (Rinn et al., 2002, cited in Verdejo-Garcia & Perez-Garcia, 2005).

TREATMENT The particular construct of denial is one that has various meanings within the field of psychology. Understanding its function with substance abusers and determining answers to essential questions is vital in determining effective treatment plans. For example, given that there is impairment in substance abusers self-awareness, to what extent can insight-oriented therapies be effective? With drug addiction seen as a cognitive disorder, which cognitive therapies may be most effective? Similarly, with our greater understanding of the neurological circuitry in addiction, how can psychopharmacological interventions best improve neuropsychological functioning? Also, if improved self-awareness is the goal, how can treatments be devised without running the risk of incurring greater negative affect leading to greater substance use? Some research offers hope and direction in designing effective treatment. For example, studies involving activation of the anterior cingulate cortex (Grusser et al., 2004; Paulus et al., 2005; Garavan et al., 2008, cited in Goldstein et al., 2009), indicate positive outcome in alcoholics, methamphetamine and cocaine users. The wellestablished role of the orbitofrontal cortex (Rolls, 2000, as cited in Goldstein et al., 2009) in reversing stimulus-reinforcement associations also suggests a positive role in insight and awareness. However, most current treatment for drug addiction falls within more traditional approaches, ignoring the wisdom of neuroscience.

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The treatment-as-usual for alcohol or other substance abuse in the United States is based almost exclusively on the 12-step, Hazelden, or Minnesota model. This treatment modality is based on the premise that addiction is a disease, most likely genetic, and not controllable unless one is completely abstinent. Furthermore, addiction is considered incurable and irreversible. Unfortunately, there have been a number of research studies that indicate that the disease model is not very effective in treating addiction. Empirical evidence now points to the fact that substance use is a continuously distributed phenomenon, ranging from problem use to dependence, and not a discrete entity in which one diagnosis fits all. Thus, people who may be problem drinkers but are not alcoholics, for instance, are not getting the help they need. Also, the fear of labeling and stigma (i.e., I am an alcoholic), and the negatively-tinged moral stance directed towards abusers is a major barrier to treatment entry. Empiricallybased treatments, on the other hand, have personalized, non-judgmental approaches that lower resistance and increase awareness of ones abuse and engagement in treatment. Evidence-based treatments In determining what constitutes as evidence-based treatment, Miller et al. (2005), examined the conclusions of 10 reviews of evidence-based treatments from seven research groups. The studies more than a thousand controlled clinical trials in the literature for alcohol, tobacco, and illicit drugs - ranged from randomized clinical trials, the gold-standard research design of the U.S. Food and Drug Administration (FDA) for approving pharmacotherapies, to quasi-experimental and correlational studies. In addition, anecdotal case reports, professional opinion and best practice guidelines

Neurocognitive underpinnings of denial and decision making developed by clinician consensus, such as was used to develop the Treatment

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Improvement Protocols published by the U.S. Center for Substance Abuse Treatment, were considered. Among the meta-analysis, 12-step programs fared 13th from a list of 29 treatment modalities. Topping the chart were motivational interviewing, cognitivebehavioral treatments, and community reinforcement approaches. Thus, these are the treatments that I will now discuss. Motivational interviewing For addicts, the notion of hitting bottom was often thought to be necessary for a person to admit he or she had a problem and to accept help. Those who did not reach that stage were thought not to be sufficiently motivated, Over the past three decades, however, there has been a gradual yet dramatic shift in thinking about motivation for change (Miller, 2005). With theoretical underpinning from self-determination theory, a transtheoretical model for change emerged, in which people are thought to pass through four discrete stages: precontemplation, contemplation, preparation, and action/maintenance. The transition between each stage is dependent upon various motivational tasks. Also, there was new thinking about the addictive personality. After considerable numbers of research studies on alcoholism, it was evident that people with alcoholism appeared to be as variable in personality as the general population. Motivation was seen as a result of an interaction between the drinker and those around him or her. Motivation was no longer something one has, but rather something that one does. It involves the recognizing of a problem, searching for a way to change, and then beginning and sticking with that change strategy (p. 134).

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Motivational interviewing consists of four strategies: expressing empathy for the patients problems, developing discrepancy between how the patient is acting and how that behavior interferes with other life goals, rolling with the patients resistance, and supporting self-efficacy. Within the developing discrepancy strategy there is room for the therapist to assist the substance user with feedback on areas in which the lack of self awareness and denial is playing into repeated patterns of use and abuse. The FRAMES model is currently seen as a major form of motivational enhancement which includes these strategic elements. The six key elements upon which the FRAMES acronym is based: offering non-jugmental Feedback on risks; stressing personal Responsibility for changing; offering Advice to change when appropriate; providing a Menu of alternative strategies for change; communicating Empathy for the patient; and facilitating a sense of Self-efficacy. Organizations, such as The Center for Motivation and Change in Manhattan, utilizing motivational interviewing techniques among other cognitive-behavioral and psychodynamic approaches, are reporting excellent results (from personal training at the Center, summer 2009). Cognitive-behavioral approaches Behavioral theories view psychoactive substance use disorders (PSUDs) as resulting from a combination of factors presumed to interact in different ways to produce PSUDs depending on each individuals unique characteristics and environment. Basic assumptions of cognitive-behavioral treatments (CBT) include the following: behavior is largely learned, rather than determined by genetic factors; the same learning process that creates problem behaviors can be used to change them; behavior is largely determined by contextual and environmental factors; and covert behaviors (thoughts,

Neurocognitive underpinnings of denial and decision making feelings) can change with the application of learning principles (Rotgers, 1996).

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Additionally, actually engaging in new behaviors in the contexts in which they are to be performed is a critical part of change. Like motivational interviewing, a critical task of CBT is to foster motivation, but it also teaches or re-teaches important coping skills, such as craving management and works to enhance interpersonal functioning, communication skills and social support. These goals that can target many of the cognitive deficits that remain out of awareness in the denying user. Amongst the many forms of CBT, The Community Reinforcement Approach (CRA) is seen as most effective, but other approaches include behavioral marital therapy, contingency management, and dialectical behavior therapy. Systematic desensitization and cue exposure therapy are two especially useful CBT strategies that can aid in relapse prevention by bringing into awareness the stimulating effect of drug cues on the amygdala system. CRA and Community Reinforcement Approach and Family Training (CRAFT) The CRA is a comprehensive behavioral intervention for substance-abuse problems that focuses on multiple problem areas in an individuals life. It utilizes social, recreational, familial, and vocational reinforcers to aid in the recovery process. The reinforcing community includes family, friends, work/school, church, and social activities. This operant program attempts to rearrange environmental contingencies such that sober behavior is more rewarding than drinking or drugging, and accomplishes this through positive reinforcement and specifically avoids the use of confrontation (Smith et al., 2003). The CRA was the first of two treatments developed. However, since it is common for individuals with substance use disorders to be

Neurocognitive underpinnings of denial and decision making uninterested in (due to lack of self-awareness and denial) and even opposed to

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treatment, CRA was modified so that it could work through concerned family members and friends of the addict as part of a programmatic effort to get the individual to seek treatment. Central clinical components include sobriety sampling, developing a treatment plan that may include optional use of disulfiram or antabuse, behavioral skills training (such as improving impulse control and decision making skills), social and recreational counseling, CRA marital therapy, CRA relapse prevention, and other strategies (such as job counseling). Psychopharmacological interventions Abusable substances affect the limbic system of the brain. When dopamine is released, neurotransmitters attach to specific receptors in the brain which cause a pleasure response or high. Repeated stimulation of these receptors creates tolerance, as well as withdrawal. In addiction, there is a decrease in the dopamine receptors which reduces sensitivity to anything rewarding; the high is decreased, while the craving is increased. Substance abuse treatment programs refer to the repeated attempts to replicate the first high as chasing the dragon. The purpose of most pharmacotherapies is to target the brain receptors or neurotransmitters/neuromodulators that are dysregulated in addiction to a particular drug of abuse (Miller & Carroll, 2006, p. 241). Psychopharmacological interventions for substance abuse tend to fall within four categories: agonists, indirect agonists, partial agonists, and antagonists. Robust principles from drug-based research suggest that agonist replacement therapies have the most efficacy for some drugs, such as methadone for heroin. Agonist therapies

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have advantages in that they do not require detoxification, they can prevent withdrawal, and at adequate doses, they can reduce the reinforcing effects of the abused drug by blocking the involved brain receptor. Partial agonists, such as buprenorphine for opiates, which have milder agonist properties, less abuse liability, and greater safety, can be very useful for office-based practice. Antagonists of specific receptors have generally been found to be ineffective due to problems with adherence, the need for detoxification, and side effects. Antagonists may be more beneficial with alcohol abuse, because the antagonist blocks only a subset of the drugs actions and are less likely to precipitate a withdrawal syndrome or result in discontinuation of the medication. Indirect methods of inhibiting a drugs reinforcing potential (either positive or negative reinforcement) that appear promising include medications that enhance the function of the GABA (a major inhibitory neurotransmitter) system (e.g., topiramate for alcoholism) or increase tonic levels of dopamine (e.g., disulfiram for cocaine)(from a lecture by Rita Goldstein at the Stony Brook University Counseling Center where I work as an Extern). Drugs that primarily make the drug of choice aversive (e.g., disulfiram for alcoholism), are likely to be associated with compliance problems. Pharmacotherapy can play a role at different stages of the recovery cycle including initial abstinence and relapse prevention. The type of pharmacotherapy needed at each stage may vary. All studies of pharmacological treatments have incorporated some kind of counseling, from basic education about how to use the medication to comprehensive behavioral approaches. The intensity and nature of the behavioral treatment component can influence the overall outcome of treatment for an individual patient. Combining therapies, such as cognitive-behavioral approaches with

Neurocognitive underpinnings of denial and decision making psychopharmacological interventions, offers the greatest support in adhering to treatment. Psychodynamic approaches Although psychodynamic therapy is considered one of the less effective treatments for addiction, I believe it should be considered, at least as an adjunctive therapy. The one-on-one nature of the therapeutic setting is conducive to understanding the nature, prognosis and possible treatment of addiction for the individual person. Winnicott (1960) wrote, Changes come in an analysis when

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traumatic factors enter the psychoanalytic material in the patients own way, and within the patients omnipotence. (p. 37). Lisa Director, a psychoanalyst who has worked successfully in the field of substance abuse for many years, claims, Psychoanalysis has much to offer the chronic substance user: while most drug treatment seeks to end substance-abusing behavior, the psychoanalytic effort would encompass this goal and extend beyond it to explore the omnipotent state that finds fruition in drug use and in other patterns of behavior in his or her life. In effect, the analytic tack would be to treat the patients drug use but seek to disengage such a symptomatic outbreak from the underlying self-state, which has needed to be preserved for its history and meaning to the person, and for that reason, warrants understanding (p. 569). Director believes that the reason many users devotion to their habit outlasts its delivery of pleasure is suggestive of unresolved relational dynamics. Drugs, drug paraphernalia and the various effects on varying mood states and methods of administration service a wide a range of relational needs. From this perspective, the

Neurocognitive underpinnings of denial and decision making therapeutic aim is to find the relational bind partly embedded in a persons drug use, formulate it as conflict in symbolic terms, and revisit it in the transference, alongside

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new connections. Meaning though by no means always or solely effective works to dismantle addiction, by serving to transpose dynamics into terms of expression and forms of object relationship that are more accessible to exploration and change (p. 571). Director adds: . . .one more reason why psychoanalysts trained in treating addiction are uniquely suited to be of help to substance users, as compared with other treatment professionals: We promote the choice of sobriety, of health overall, but recognize the complexity of the choice, which lends essential pathos to the human struggle (p. 582) Regina Pally (2007) offers a technique that helps to bridge neuroscience and psychotherapy. In her own therapeutic work, she explains neuroscience concepts to patients to help them understand the link between past relational issues and the repeated attempts to replicate those patterns in current behavior. She writes, Unfortunately, some children receive far less than is optimal [in childhood] and must erect defenses against powerful negative affect states early in life. These defenses lead to repetitions, which tenaciously resist conscious awareness and change. What neuroscience adds is that, in addition to defenses, repetition resists awareness and change because of deeply encoded non-consciously operating predictions (p. 863). Helping patients to recognize these patterns brings self-awareness to the surface so that it can be used to inform change.

Neurocognitive underpinnings of denial and decision making Conclusion

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Although I had hoped to learn more about the intersection between the neurocognitive underpinnings of drug addiction and treatment, what has become apparent, is that traditional treatment has been slow to integrate or even interface with findings from the neuroscientific field. Pharmacotherapies address some of the neural dysfunction and symptomatology of addiction, motivational strategies and CBT treatments address behavioral issues in drug abuse, and psychotherapy addresses underlying emotional issues, but much more needs to be done in this area. With greater understanding of the neuro-structures that most deeply relate to the processes of decision-making and self-awareness throughout the addiction cycle, including relapse, treatments need to be devised to support the substance users ability to affect change. While there may be no exclusively correct answer to which treatment may be best suited to addiction for substance users, new links combining neuroscience and psychotherapy should highlight the future direction. In addition, having a neural basis of insight and self-awareness will enable everyone in the field to work with addicted individuals with increased understanding, empathy and effectiveness.

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Neurocognitive underpinnings of denial and decision making therapeutic change. International Journal of Psycho-analysis, 88, 861-882.

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Rotgers, F. (1996). Behavioral theory of substance abuse treatment: bringing science to bear on practice. In Keller, D. S., Morgenstern, J. and Rotgers, F. (Eds.), Treating substance abuse: Theory and technique (202-240). New York: Guilford Press. Smith, J. E., Meyers, R. J., and Milford, J. L. (2003). Community reinforcement approach and community reinforcement and family training. In Hester, R. K. & Miller, W. R. (Eds.) 2003. Handbook of alcoholism treatment approaches (pp. 237-258). Boston: A & B. Verdejo-Garcia, A., & Perez-Garcia, M. (2008). Substance abusers self-awareness of the neurobehavioral consequences of addiction, Psychiatry Research, 158, 172-180. Winnicott, D. W. (1960). The theory of the parent-infant relationship. In: The Maturational Processes and the Facilitating Environment. New York: International University Press.