The Search for New Ways to Change Implicit Alcohol-Related Cognitions in Heavy Drinkers

ALCOHOLISM:CLINICAL AND EXPERIMENTAL RESEARCH Vol. 30, No. 2 February 2006 The Search for New Ways to Change Implicit Alcohol-Related Cognitions in Heavy Drinkers

Reinout W. Wiers, W. Miles Cox, Matt Field, Javad S. Fadardi, Tibor P. Palfai, Tim Schoenmakers, and Alan W. Stacy

This article summarizes a symposium on new ways to change implicit alcohol-related cognitions, presented at the 2005 Annual Meeting of the Research Society on Alcoholism in Santa Barbara, California, organized by Wiers and Cox. During the past few years, research has demonstrated that implicit cognitions predict unique variance in prospective alcohol use and preliminary results indicate that they also predict treatment outcomes. The central question in this symposium was how implicit cognitions can be changed and how the changes will inﬂuence behavior. Field presented data showing that an attentional bias for alcohol can be altered by attentional training: heavy drinkers who were trained not to attend to alcohol stimuli reported less craving and drank less beer than those trained to attend to alcohol stimuli. Schoenmakers used a similar, clinically relevant attentional retraining (AR) procedure, heavy drinkers were trained not to attend to alcohol pictures or received no training. After the training, the AR group attended less to the alcohol pictures than the control group. Fadardi described the Alcohol Attentional Control Training Program (AACTP), which makes alcohol drinkers aware of the automatic, cognitive determinants of their drinking and aims to help them to gain control over these processes. Data were presented to support the effectiveness of the AACTP. Palfai presented data showing that alcohol drinkers can be taught to use implementation intentions to gain control over their drinking, which may be used to automatically activate self-control skills in the presence of alcohol cues. In his discussion, Stacy pointed out the importance of recent cognitive theories that integrate attention and memory processes—theories that can help us better understand the mechanisms involved in AR. Together, the studies presented demonstrate that there are promising new ways in which implicit alcohol-related cognitions and their effects on drinking can be changed. After further reﬁnement, these procedures might be used in clinical interventions that have not previously addressed implicit cognitive processes. Key Words: Implicit Cognition, Attentional Bias, Dot-Probe, Alcohol-Stroop, IAT, Treatment for Alcohol Abuse, Attentional Retraining, Implicit Associations, AACPT.

INTRODUCTION ‘‘introspectively unidentified (or inaccurately identified) traces of past experience that mediate feeling, thought, or URING THE PAST decade, research on implicit action’’ (Greenwald and Banaji, 1995; see also De Dcognitive processes has become influential in alcohol Houwer, 2006). Implicit cognition approaches can be roughly and addiction research (for a overview, see Wiers and divided into 3 lines of research with their own historical Stacy, 2006). Implicit cognitions have been defined as roots and background in basic science. The first is the attentional bias (AB) approach, rooted in experimental From the Department of Experimental Psychology, Faculty of Psy- psychopathology research. In a variety of disorders, it has chology, Universiteit Maastricht, Maastricht, The Netherlands (RWW, been demonstrated that disorder-related stimuli automat- TS); the School of Psychology, University of Wales, Bangor, UK ically draw and capture attention (see for a review (WMC, JSF); the School of Psychology, University of Liverpool, Liv- erpool, UK (MF); the Department of Psychology, Ferdowsi University, Mathews and MacLeod, 2005). On alcohol use, recent Mashhad, Iran (JSF); the Department of Psychology, Boston Universi- reviews have concluded that there is an increase in AB ty, Boston, Massachusetts (TPP); the Keck School of Medicine, Los from light to heavy social drinkers to alcohol abusers Angeles, California (AWS). (Bruce and Jones, 2006; Cox et al., in press). The second Received for publication September 30, 2005; accepted November 15, line of research concerns the memory bias approach, 2005. Supported by Grant N.W.O. Vidi 452.02.005 (RWW, TS); British which is rooted in basic memory research (Stacy, 1997). Academy Grant LRG-37196 (MF); the Alcoholic Beverage Medical Re- Stacy et al. (2004) have adapted implicit memory tasks to search Foundation (TPP); and Economic and Social Research Council study alcohol and drug use and have demonstrated that Grant RES-000-22-0314 (WMC, JSF). Reprint requests: R. W. Wiers, PhD, Experimental Psychology, Uns the performance on the tasks predicts alcohol and drug 40, Universiteit Maastricht, PO Box 616, 6200 MD Maastricht, The use better than explicit measures. The third line of research Netherlands; Fax: 131 43 3884196; E-mail: R.Wiers@psychology. has relied on reaction time measures to assess implicit unimaas.nl associations, consistent with research rooted in social Copyright r 2006 by the Research Society on Alcoholism. cognition research (Fazio and Olson, 2003). The best DOI: 10.1111/j.1530-0277.2006.00037.x known assessment techniques are the Implicit Association

320 Alcohol Clin Exp Res, Vol 30, No 2, 2006: pp 320–331. CHANGING IMPLICIT ALCOHOL-RELATED COGNITIONS 321

Test (IAT, Greenwald et al., 1998) and affective priming Explicit Cognitions Alternative (Fazio, 2001). Theoretically, one would expect that the Most Negative Expectancies behaviors Interventions measures developed in these different approaches would at Reasons to Abstain Implicit least partially overlap, stimuli related to an individual’s C. New Intervention current concerns should readily be retrieved from memory cognition B -? Palfai & Ostafin Alternative and draw the person’s attention (Cox et al., in press; Heavy drinking Implicit behaviors Franken, 2003). However, it should be noted that there Cognition has been surprisingly little research directly comparing the A. NewInterventions 3 kinds of measures of implicit cognition. Heavy drinking Importantly, in all 3 approaches, there are strong indi- Field; Fadardi & Cox; Schoenmakers & cations that implicit assessment methods add something Wiers unique to the prospective prediction of addictive behaviors, beyond the information provided by explicit meas- Fig. 1. A simplified model representing different ways to use implicit cognitions in interventions: (A) One may try to directly modify implicit cognitions ures (i.e., questionnaires). For this reason, it may be useful that motivate drinking behavior. (B) Perhaps explicit cognitions can be used to to use implicit tests in conjunction with explicit tests when moderate the influence of implicit cognitions on drinking behavior. (C) Explicit the current interventions are tested (e.g., Cox et al., 2002; strategies may be used to develop automaticity for more healthy alternatives. Wiers et al., 2005). Implicit measures may uniquely predict clinically relevant outcomes such as relapse (Cox et al., 2002), and the effects of current interventions on implicit through the use of planning strategies that promote con- versus explicit cognitions appear to be unrelated (Wiers textually driven self-regulatory processes. These different et al., 2005; cf. Teachman and Woody, 2003). These and new approaches to interventions from a dual-process per- other findings (e.g., from neuroscience) have led many theo- spective are illustrated in Fig. 1. rists to consider addictive behaviors from a dual-process perspective (see many examples in Wiers and Stacy, 2006). ATTENTIONA BIAS FOR ALCOHOL CUES AND THE From a dual-process perspective, an intervention can be MOTIVATION TO DRINK ALCOHOL: ASSESSMENT OF aimed either at more explicit or at more implicit cognitive THEIR CAUSAL RELATIONSHIP WITH AN processes. Most current psychosocial interventions are EXPERIMENTAL MANIPULATION aimed at changing explicit cognitive processes, making Matt Field negative (long-term) consequences of continued use more clear, building up motivation for change, teaching strate- Current models of drug craving emphasize the recipro- gies to deal with the lures of continued drug use, etc. From cal interactions between cognitive variables and subjective a dual-process perspective, one could view such interven- drive states. For example, Franken (2003) proposed that, tions as attempts to influence explicit cognitions, which in in the experienced alcohol user, alcohol-related cues (e.g., turn could moderate the influence of the largely automatic the sight of a bottle of vodka) acquire incentive-motiva- stimulus-driven implicit cognitive system on behavior tional properties, which cause these cues to ‘‘grab the (Stacy et al., 2004). In addition, researchers in different attention.’’ The resulting ‘‘attentional bias’’ for alcohol- domains have begun to investigate new ways to directly related cues promotes an increase in subjective craving influence implicit cognitions (for a review, see Wiers et al., until eventually craving reaches a threshold level that is 2004). In anxiety research on AB, it has been demonstrated sufficient to motivate self-administration. According to than an AB can be experimentally manipulated either Franken, this mechanism could contribute to substance toward or away from the anxiety-provoking stimuli (Mac- use and abuse across a broad range of substance users Leod et al., 2002; Mathews and MacLeod, 2002), with cor- (e.g., social drinkers, tobacco smokers, opiate addicts), responding changes in behavior. These findings have and it may also explain relapse to drug-taking in drug directly inspired 3 of the 4 studies presented here (Field; users who are attempting to remain abstinent. Similarly, Fadardi and Cox; and Schoenmakers and Wiers), which according to the ‘‘elaborated intrusion’’ theory of desire are, to the best of our knowledge, the first 3 attempts of (Kavanagh et al., 2005), cognitive elaboration on motiva- ‘‘attentional retraining’’ (AR) in the area of alcohol abuse. tional states (including focusing the attention on drug- The fourth study (Palfai and Ostafin) adopted a differ- related stimuli in the environment) can increase the ent strategy, rather than trying to change the implicit strength of those motivational states, and this mechanism processes that promote drinking alcohol, it investigated could contribute to the potentiation of a variety of subjec- whether interventions can be developed that enable tive drive states, including hunger and drug craving. hazardous drinkers to automatically activate self-control– Consistent with these models, experimental evidence related responses in high-risk contexts. Research on the suggests that alcohol abuse is associated with biases in the effect of ‘‘implementation intentions’’ on self-control– cognitive processing of alcohol-related stimuli. For exam- related responses is presented to exemplify how automatic ple, some studies have used the modified Stroop task appetitive responses to alcohol cues can be modified to demonstrate that alcohol abusers and heavy social 322 WIERS ET AL. drinkers are slower to name the color of alcohol-related attentional avoidance of the alcohol-related pictures. After words than control words (e.g., Sharma et al., 2001; Stor- attentional training, the effectiveness of the manipulation mark et al., 2000), which suggests that problematic alcohol was confirmed, in that the magnitude of ABs was signifi- users find alcohol-related words difficult to ignore, and cantly increased in the attend alcohol group, t(19) 5 they ‘‘grab the attention.’’ Other studies have used the 3.41, po0.01, yet significantly reduced in the avoid visual probe task, in which participants make rapid man- alcohol group, t(19) 5 2.41, po0.05, compared with a ual responses to visual probe stimuli, which are presented pretraining baseline. The manipulation also influenced immediately after the display and offset of a pair of words measures of the motivation to drink alcohol in the predict- or pictures. Studies using this task have found that drug ed direction. In the attend alcohol group, subjective users are faster to respond to probes that appear in the alcohol craving increased after attentional training, location of drug-related pictures rather than control compared with a pretraining baseline, t(19) 5 2.70, po0.05, pictures, which suggests that their attention is preferentially although craving did not decrease in the avoid alcohol allocated to the spatial location of the drug cues. Using group after attentional training, t(18) 5 1.16, p40.1. this task, several investigators have demonstrated AB for Furthermore, after attentional training, participants were alcohol-related pictures in heavy social drinkers (Field given the opportunity to consume up to 250 mL of beer, et al., 2004; Townshend and Duka, 2001) and in other and the attend alcohol group consumed significantly more drug users, including drug-dependent populations (for a beer than the avoid alcohol group, F(1, 37) 5 4.64, po0.05. review, see Robbins and Ehrman, 2005). Moreover, ABs These results demonstrate that (a) AB for alcohol-related for drug-related cues are associated with subjective cues can be experimentally increased or decreased when craving, in different classes of drug users, including social manipulated directly, and (b) when AB for alcohol-related drinkers (Field et al., 2004, 2005). cues is experimentally increased, this can increase the Although subjective drug craving and AB appear to be motivation to drink alcohol, as assessed by subjective craving associated with each other, the causal relationship between and a behavioral measure of alcohol consumption. There these variables is unclear. Attentional biases may simply are several important theoretical and clinical implications be a consequence of the underlying motivational state, but of these results. First, the observed reduction in AB in the an alternative possibility is that ABs could maintain or avoid alcohol group suggests that heavy social drinkers potentiate the motivational state, as predicted by Franken can exert some control over their AB for alcohol-related (2003) and Kavanagh et al. (2005). As noted by Wiers et al. cues if trained to do so. The participants were heavy social (2004), the clearest way to test the causal nature of the drinkers recruited primarily from a student population, so relationship between cognitive processing biases and motiva- it remains to be seen whether the results would generalize tional states is to experimentally manipulate cognitive biases to alcohol-dependent populations. However, other studies and then explore the effects of these manipulations on have demonstrated that, in alcohol-dependent patients, measures of motivational state. As described below, results AB for alcohol-related cues is reduced after successful from a recent study are consistent with the notion that an treatment (Townshend and Duka, 2003), which suggests experimental manipulation of AB for alcohol-related cues that reduction of ABs could be a realistic treatment goal. can influence the motivation to drink alcohol. Second, the observed increase in subjective alcohol crav- Field and Eastwood (2005) reported an experiment in ing after attentional training in the attend alcohol group which a modified visual probe task was used to ‘‘train’’ appears consistent with Franken’s (2003) model, which social drinkers to direct their attention either toward, or predicts that increases in AB for drug-related cues should away from, the location of alcohol-related cues. Partici- produce increases in subjective drug craving. Franken pants (heavy social drinkers who reported regular alcohol (2003) predicts that this bidirectional relationship consumption at levels above those recommended by the contributes to an escalation of subjective craving and UK Department of Health, N 5 40) were randomly allo- drug-seeking when drug-related cues are present. When cated to experimental groups, ‘‘attend alcohol’’ or ‘‘avoid drug users experience craving, this promotes a search of alcohol.’’ Participants in the attend alcohol group the environment for drug-related cues; yet when these completed a modified visual probe task in which pairs of cues are detected and attended to (‘‘attentional bias’’), alcohol-related and control pictures were presented on a this produces further increases in craving, ultimately computer screen. In this group, visual probes always increasing the likelihood of drug consumption. replaced the alcohol-related (rather than control) pictures. The study reported by Field and Eastwood compared Because participants were instructed to respond to the the effects of 2 manipulations with each other: 1 designed probes as rapidly as possible, it was hypothesized that this to increase AB (attend alcohol group) and 1 designed to manipulation would induce an AB for the alcohol pictures. reduce it (avoid alcohol group). It is helpful to compare the Participants in the avoid alcohol group completed a results reported by Field and Eastwood (2005) with those similar procedure, with the major difference that, in this reported by Schoenmakers and Wiers (this article). The group, visual probes always replaced control (rather than latter investigators used an experimental procedure alcohol related) pictures, which was intended to induce similar to that described by Field and Eastwood, and they CHANGING IMPLICIT ALCOHOL-RELATED COGNITIONS 323 compared alcohol craving and AB in 2 different experi- training produces long-term rather than transient changes mental groups. In the Schoenmakers and Wiers study, in attentional processing and alcohol craving. Second, the 1 group was trained to direct their attention away from results reported by Field and Eastwood (2005) suggest that alcohol-related cues (comparable with the avoid alcohol cognitive factors contribute to the effects of alcohol cue group described by Field and Eastwood, (2005). The other exposure on subjective alcohol craving. In that study, the group in the Schoenmakers and Wiers study was not attend alcohol and avoid alcohol groups received equal trained to direct their attention toward or away from exposure to alcohol-related cues; the critical difference alcohol-related cues, so that this group can be more appro- between the groups was that 1 group was encouraged to priately described as a true control group, in contrast to attend to the alcohol cues, whereas the other group was Field and Eastwood’s attend alcohol group, who were encouraged to direct their attention away from the cues. trained to direct their attention toward alcohol-related Given that only the attend alcohol group reported an in- cues. Field and Eastwood reported significant group dif- crease in subjective craving after attentional training, it ferences in alcohol craving and beer consumption after appears that mere exposure to alcohol-related cues is not attentional training; Schoenmakers and Wiers did not sufficient to produce an increase in alcohol craving. observe differences between their groups on these meas- Instead, the alcohol cues must become the focus of ures. In both studies, the ‘‘avoid alcohol’’ groups did not attention before they can elicit an increase in craving. report a decrease in the urge to drink alcohol after attentional training (relative to a pretraining baseline), even ATTIONAL RETRAINING IN HEAVY DRINKERS though the attentional training manipulation produced a Tim Schoenmakers and Reinout W. Wiers significant reduction in AB in both groups. Taken together, these results suggest that a decrease in AB is not sufficient Alcohol abusers and heavy drinkers have an AB for to produce a decrease in craving. If this is the case, it alcohol stimuli (Townshend and Duka, 2001; Wiers et al., would not be promising for the use of attentional training 2004). This means that they will selectively attend to these techniques as a clinical intervention, because a decrease in stimuli very rapidly (Stormark et al., 1997) or have a dif- AB may not be accompanied by a decrease in the urge to ficulty disengaging from the stimuli (Field et al., 2004). drink alcohol. However, it is also important to consider This bias is generally assumed to increase craving and that urges and craving for alcohol produced by alcohol- subsequent drinking behavior (e.g., Franken, 2003). In related stimuli, which presumably result from extensive psychopathology, the same assumption is present for AB experience of alcohol consumption and exposure to alco- and emotional vulnerability (Mathews and Macleod, hol-related cues, are probably very difficult to eliminate or 2005). A number of researchers have investigated this reverse. The brief experimental manipulations used in assumed causality and have succeeded in directly changing these experiments may have been insufficient to produce a AB and observing a subsequent change in emotional decrease in craving in the avoid alcohol groups (cf. experience (see Mathews and Macleod; De Jong et al., Fadardi and Cox, this article). Future studies may wish to 2006; MacLeod et al., 2002, for reports on social phobia explore this possibility, perhaps by increasing the number and general-anxiety disorder). This search for a causal role of attentional training trials. of AB is now under investigation in alcohol research as well. Finally, it is important to consider how the cue-reactiv- A method to directly change AB in emotional vulnera- ity literature can help to explain the results reported by bility research has been developed by MacLeod et al. Field and Eastwood (2005). There are numerous demon- (2002). In their ‘‘attentional retraining,’’ participants scor- strations that exposure to alcohol-related cues can increase ing moderate on emotional vulnerability were subjected to subjective alcohol craving (see Carter and Tiffany, 1999, an adaptation of the visual probe classification task. In a for a review), and one might question whether attentional standard classification task, 2 stimuli (words or pictures) training simply involved a greater level of exposure to representing 2 categories are presented on a computer alcohol cues in the attend alcohol group than the avoid monitor. After 500 milliseconds, the stimuli disappear, alcohol group—which might explain the observed changes and a probe consisting of 1 or 2 pixels replaces 1 of the 2 in subjective craving in the attend alcohol group after stimuli. By pressing 1 of 2 buttons, participants can differ- attentional training. Two important issues arise here. First, entiate between the probes. A faster response to a probe in attentional training may involve long-lasting changes in place of the stimuli of 1 category indicates an AB for that the cognitive processing of alcohol-related cues. In the category relative to the alternative. In most trials of the results reported by Field and Eastwood (2005), AB for MacLeod et al. retraining procedure, the probe replaced alcohol cues was increased following attentional training threatening words for 1 group and neutral words for in the attend alcohol group, but the avoid alcohol group the other group. The former group of participants learned actually showed attentional avoidance of the alcohol cues to automatically attend to the threatening stimuli (as following training. Longer-term studies, using additional measured by the probe classification task) and showed measures of the attentional processing of alcohol-related more negative reactions to a subsequent stress task than cues, are required to investigate whether attentional the latter group. 324 WIERS ET AL.

We recently used a similar retraining paradigm for Consistent with Field (this article), our retraining did not changing AB in male heavy drinking undergraduate affect craving or drinking behavior (craving and drinking students (M 5 40 Dutch standard drinks per week, which were increased in his ‘‘attend alcohol’’ group). Our retraining is equivalent to 29 US 14-g drinks). The retraining was a was mainly effective for the old pictures, whereas MacLeod clinically relevant one; participants in the experimental et al. (2002) reported generalization for new stimuli. There condition were trained to attend to soft-drink stimuli are 2 possible reasons for this discrepancy. First, it may be rather than the alternative category of alcohol stimuli, due to a difference in design. Namely, MacLeod et al. and the participants thereby learned to avoid the alcohol trained 1 group to attend to 1 category and the other group stimuli. By training drinkers to automatically focus to attend to the other category (cf. Field, this article). In on soft drinks and avoid focusing on alcohol, their contrast, we trained 1 group to attend to a category and attention should focus on the healthier alternative in the other group simply to complete filler trials. Hence, in actual drinking settings. The other half of the partici- MacLeod’s paradigm a larger gap was created between pants was randomly assigned to the control group, scores of the experimental and control group (see Fig. 2) and they performed the test-only probe classification compared with our design. trials. We were interested in the effect of the retraining Second, it might be that more different picture pairs are on craving and subsequent drinking behavior. Also, we needed for generalization of retraining. MacLeod et al. explored whether the retraining generalized to (a) other (2002) used 48 different pairs of stimuli and repeated them stimuli that were not used in the training and (b) another 12 times in their retraining. We used 12 different pairs of measure AB. stimuli and repeated these 48 times in our retraining. In our procedure, participants (all of whom were regular MacLeod et al. may have trained on all 48 stimuli in the beer drinkers) were first sip-primed with beer to increase category, whereas our retraining may have increased focus the likelihood of finding AB in heavy drinkers (Duka and on specific stimuli. Townshend, 2004). The participants next performed a Together, the studies of Macleod et al. (2002), Field (this visual probe task with alcohol and soft-drink pictures. article), and ours indicate that training to attend to the Immediately thereafter, the retraining started for the undesirable response (threat stimuli, alcohol pictures) may experimental group. The training consisted of 576 training be easier than the more clinically relevant retraining away trials (with probes always replacing the soft-drink stimuli) from these stimuli. However, Fadardi and Cox (this arti- and 48 filler trials in which probes replaced both alcohol cle) have decreased the clinically relevant AB (measured by and soft-drink stimuli. The control group completed 624 a Stroop task) in multiple training sessions. To serve as a trials with the probes replacing each category of pictures clinical tool, retraining might work better in multiple on 50% of the trials. Immediately following the training, sessions. If reduction in AB does decrease craving, it might participants performed a visual probe task, with both the be useful in reducing alcohol abusers’ and other heavy (old) pictures used in the training and the new pictures drinkers’ urges to drink and their subsequent drinking from the same categories. Thereafter, an adjusted flicker behavior. Theoretically, retraining does seem to be a useful task (Jones et al., 2003) consisting of 4 trials was adminis- means to assess the causal role of AB on craving if AB is tered. Craving was measured before and after the manip- increased. But it is in the interest of both theorizing and ulation using a 1-item VAS scale. Drinking behavior was clinical applications to conduct more research to explore measured using an alcohol diary. generalization in AR both for new stimuli and for other Inconsistent with earlier findings (Field et al., 2004; measures of AB. Townshend and Duka, 2001), results indicated no significant AB in the pretest. In the posttest, however, participants in the retraining group had an AB for the soft-drink stimuli, but the controls did not. Thus, the retraining was successful in creating an automatic focus on soft drinks. We found no significant interaction for picture type (old vs new) with group, indicating that the effect did not differ for old versus new pictures. However, given the theoretical importance of generalization and in line with Macleod et al. (2002), we further explored differences for old versus new pictures. This was done by analyzing retraining effects for old and new pictures separately. Here, we found that AB was significant only for old pictures. Therefore, the retraining effect might not have fully generalized. Fig. 2. Differences in design and hypothethical outcomes between the There was no effect of the retraining on the flicker study of Schoenmakers and Wiers (this article) and the study of Field (this task, but this task did detect an overall AB for alcohol. article) and MacLeod et al. (2002). CHANGING IMPLICIT ALCOHOL-RELATED COGNITIONS 325

ALCOHOL ATTENTION CONTROL TRAINING PROGRAM excessive drinkers gain better control over their attentional distraction for alcohol-related stimuli. The interven- Javad S. Fadardi and W. Miles Cox tion serves 2 important functions. First, it aims to correct Basic research within the framework of Cox and Klin- the uncontrollability with which excessive drinkers are ger’s (2004) cognitive-motivational model of alcohol use drawn to alcohol instead of attending to other kinds of indicates that there are 2 major cognitive-motivational stimuli. Second, it aims to reduce the length of time that determinants of drinking, (a) alcohol abusers’ motivational drinkers need to divert their attention away from alcohol structure, which prevents them from focusing on and suc- once it has captured their attention. cessfully achieving healthy, adaptive goal pursuits as an The AACTP is designed to help drinkers to become aware alternative to drinking alcohol, and (b) their AB for alcohol- of the automatic cognitive aspects of their drinking. It helps related stimuli, which results from their continuous them gain better control over these processes through a current concern for consuming alcohol; alcohol AB reflects series of systematic, volitional exercises aimed at developing drinkers’ preoccupation with drinking and their selective their inhibitory mechanisms responsible for unintentional distractibility for alcohol-related cues. Alcohol AB and distraction by alcohol stimuli. The AACTP is based on motivationalstructure are the 2 significant predictors of individualized, hierarchical goal setting and provides excessive drinking that remain after a variety of other deter- trainees with immediate feedback about their performance. minants have been controlled (Fadardi and Cox, in press). Two of the categories of stimuli used in the training are The alcohol-Stroop test (Cox et al., in press) is a robust individually presented on a monitor and comprise single paradigm for studying AB. On the alcohol-Stroop test, par- alcoholic or soft-drink bottles, each of which is surrounded ticipants respond to stimuli presented in different colors by either a colored background or border in 1 of 4 colors— that are either alcohol related (e.g., gin) or neutral (e.g., red, yellow, blue, or green. There is a third, more difficult window). The participant’s task is to name the color of each category of stimuli, in which pairs of bottles appear word as rapidly as possible, while ignoring the word’s simultaneously on the screen; the participant is instructed meaning. Alcohol interference occurs when participants to respond to the outline color of each nonalcoholic bottle react more slowly to alcohol-related words than neutral ones. as quickly as possible, while ignoring the alcohol-related Alcohol interference has been consistently observed among part of the stimulus. heavy social drinkers (e.g., Stewart et al., 2002) and alcohol Each session begins with the single stimuli with colored abusers (e.g., Stormark et al., 2000), but the degree of inter- backgrounds (easiest in the series), proceeds with the single ference is proportional to participants’ actual drinking. stimuli with colored outlines (intermediate difficulty), and Alcohol AB signifies drinkers’ preoccupation with alco- continues with the paired stimuli (most difficult). After hol and lack of confidence in their ability to overcome completing each session, the participant is given in the fol- urges to drink, despite their desire to remain abstinent lowing graphical feedback: (a) number of errors and mean (McCusker, 2001). In fact, drinkers’ attempts to reduce reaction time to the alcoholic and nonalcoholic stimuli their drinking increase their AB for alcohol-related stimuli, and (b) interpretation of the scores. The goal is to motivate which in turn intensifies their impulses to drink (e.g., Cox et participants to actively take part in the program in a al., 2002). Such impulses can overshadow the person’s meaningful and goal-directed way. Prior to each session, intentions not to drink, leading to a vicious cycle of the participant is encouraged to set a goal for decreasing repeated relapses. According to Robinson and Berridge’s his or her reaction times to the colored dimension of the (2001) incentive-sensitization theory, repeated adminis- nonalcoholic bottles; this procedure leads to systematic tration of alcohol causes the neural pathways in the reductions in the time limit within which the trainee should midbrain and frontal lobes to become sensitized to alcohol- make a response. The goal is for each trainee to improve related stimuli. When a drinker encounters these stimuli, attentional control until his or her own performance a conditional motivational state in the sensitized brain plateau has been reached. However, every effort is made is triggered, leading the person to crave and search for to insure that participants always terminate training alcohol and ingest it. This suggests that motivational inter- sessions feeling good about their progress. ventions are incomplete if they fail to address the sensitized In 1 evaluation, detoxified alcohol abusers who received attentional system. the AACTP showed progressive reductions in their alco- It was in this context that the Alcohol Attention Control hol-specific AB (Fadardi, 2003). The alcohol specificity of Training Program (AACTP) was developed. It is a tech- the program was established by finding no generalization nique for helping excessive drinkers to overcome their of the effects of the training to other personally relevant automatic distraction for alcohol, which plays an impor- (i.e., concern-related) stimuli. tant role in their inability to moderate their drinking, Another study tested the effectiveness of the AACTP in especially in high-risk situations (Stasiewicz et al., 1997). reducing the alcohol AB of excessive drinking university The AACTP is designed to neutralize the cognitive proc- students (N 5 54, 74% female). Participants completed an esses involved in the automatic chain of drink-wanting, alcohol consumption questionnaire (males’ mean weekly drink-seeking, and drink-taking behaviors, by helping units of alcohol 5 53.79, SD 5 32.49; females’ mean weekly 326 WIERS ET AL. units 5 43.59, SD 5 28.65); the Positive Affect Negative number of investigators have found it useful to think Affect Scale (PANAS; Watson et al., 1988); Readiness to about the challenge of self-control as the selection and Change Questionnaire (RTCQ; Heather et al., 1991); and pursuit of conflicting goals (Fishbach et al., 2003; Karoly, classic, alcohol-related, and concern-related Stroop tests. 1999). Limiting one’s alcohol use involves the ability to ac- After practicing the AACTP 4 times (twice in 2 weekly tivate cognitive-motivational representations that support a sessions), participants completed post-test measures, self-control goal in a context in which a competing appeti- except for the alcohol consumption questionnaire because tive goal (e.g., affect regulation) might be highly salient it was unreasonable to expect actual reduction in the (Palfai, 2004). What makes self-control of alcohol particu- amount of alcohol consumed during the course of a week. larly difficult is the fact that goal processes that support At baseline, there was no difference between males and drinking might operate quite differently than those that females in the amount of alcohol consumed, PANAS scores, support self-control skills (Metcalf and Mischel, 1999; readiness to change, or interference scores on any of the 3 Tiffany, 1990). Repeated substance use may result in strong versions of the Stroop test (for all comparisons, p40.05). memory associations between contextual cues and subst- Alcohol AB was correlated with the amount of alcohol ance-related information. Consequently, the self-control of consumed after participants’ scores on the PANAS and alcohol and other substance use is often challenging their classic Stroop interference scores had been partialed because the conflict is one between an automatic appetitive out (p 5 0.04). A repeated-measures analysis of variance response and an effortful inhibitory response. performed on the alcohol and classic Stroop interference One of the central challenges for individuals trying to scores at Time 1 and Time 2 showed a significant interac- regulate their alcohol use is to activate self-control–related tion between Time (i.e., pre- vs posttest) and Task (i.e., information within a context that supports the conflicting alcohol- vs concern-related interference), F(1, 45) 5 8.26, behavior of alcohol consumption. Coping skills will be p 5 0.006, Z2 5 0.16. Three-way and 4-way interactions more effective to the extent that they are automatically between Time, Task, Alcohol Consumption (low, medium, activated and sustained in context. How is this achieved? and high), and RTC (low, medium, and high) were not The most straightforward method is to develop automa- significant. Post hoc t tests for dependent samples showed ticity through practice (Shiffrin and Schneider, 1977). that the only significant change from Time 1 to Time 2 was Repeated training in which one generates a coping in alcohol AB, t(53) 5 2.23, p 5 0.03. In a separate repeated- response in the context of high-risk cues is central to many measures analysis of variance, Time (i.e., Time 1, Time 2) skill-based interventions (e.g., Monti et al., 1989). Central and RTC (3 levels of Precontemplation, Contemplation, to this approach is the ability to provide extensive practice and Action) were entered as within-groups variables and with a broad range of high-risk cues, so that skills can be Alcohol Consumption (low, medium, and high) as the better utilized in context. between-groups variable. The only significant effect was A second method of increasing the activation of self- an interaction between Time and RTC, F(2, 102) 5 3.62, regulatory responses in high-risk contexts is through the p 5 0.03, Z2 5 0.07. A post hoc t test for dependent samples use of planning strategies. Recent social cognition research showed that the heaviest drinkers (M 5 59.80, SD 5 20.01) has provided some promising avenues through the had a significant increase on the Action subscale of RTC study of implementation intentions (Gollwitzer, 1993). from the pre- to the posttest, t(53) 5 2.48, p 5 0.02, Implementation intentions are planning strategies that suggesting that their reductions in alcohol-related AB were prospectively link specific cues to actions in the form accompanied by an increase in their motivation to change ‘‘When I encounter x at time y I will do z’’ (Gollwitzer, their drinking. 1999). A number of studies have shown that goals are In conclusion, the AACTP allows drinkers to become more likely to be realized when participants form specific aware of the unconscious, automatic cognitive aspects of plans about when, where, and how the goals are to be their drinking behavior, and it helps them gain better control pursued (e.g., Murgraff et al., 1996; Sheeran and Orbell, over these processes through a series of volitional exercises. 1999). Gollwitzer (1999) suggested that implementation A systematic evaluation of the AACTP with excessive drink- intentions will facilitate goal attainment by increasing the ers from the community was recently completed. It measured accessibility of means/actions specified in the implemen- the effects of the AR on reductions in both alcohol AB and tation intentions. Forming an implementation intention to alcohol consumption. The preliminary results are promising. engage in a specific action in the future will make it more likely that the action will come to mind within the specified DEVELOPING STRATEGIES TO CHANGE context. The ability of implementation intentions to CONTEXTUALLY ACTIVATED RESPONSES TO increase the accessibility of information has been demon- ALCOHOL CUES strated in a variety of ways, including superior recall of action events and speed of action initiation (Gollwitzer, Tibor P. Palfai and Brian D. Ostafin 1993). When speed of response is emphasized, for example, For many problem drinkers, limiting alcohol use is a implementation intentions have been shown to facilitate challenge that typifies the struggle of self-control. A responses to target cues (i.e., a specific number) on a CHANGING IMPLICIT ALCOHOL-RELATED COGNITIONS 327 vigilance task without interfering with response speed to (Beverage; alcohol/placebo)Â2 (Strategy; implementation nontarget cues (Webb and Sheeran, 2004). Brandstatter intention/control) between-groups design. et al. (2001) conducted a number of experiments that Following a brief rest period, participants were presented explored the question of whether implementation intentions with 2 glasses of either high-alcohol beer (Duvel, 8.5%/ increase the speed of action initiation within relevant volume) or placebo beer (Clausthauler with bitters added). contexts, even under high cognitive load. In 1 study, The quantity administered was calculated from a formula participants completed a vigilance task that involved key based on gender and weight and designed to achieve a pressing in the presence of a number. Half of the sample BAC of 40 mg%. Participants consumed the beverages was asked to make a commitment to respond to a specific over a 10-minute period. Following the beverage adminis- number through the use of implementation intentions. tration phase, participants completed breathalyzer tests Results showed that participants who used implemen- and measures of mood and urges to drink every 5 minutes. tation intentions were faster than control participants to The postconsumption categorization task, based on identify the target, regardless of cognitive load. the modified IAT, began at 18 minutes after beverage This research suggests that implementation intentions administration. Another iteration of the incongruent may be particularly relevant to drinkers’ efforts to control critical block (80 trials of ‘‘alcohol’’ and ‘‘avoid’’ on 1 key their alcohol use. When individuals have sufficient cogni- and ‘‘electricity’’ and ‘‘approach’’ on the other key), and tive capacity, they may be able to manage or override participants were reminded of the task and asked to appetitive responses. However, exposure to substance- complete it as quickly as possible. Before this second related cues frequently requires that the individual retrieve incongruent block, participants in the Control condition and implement coping skills under conditions that make were asked to ‘‘try to respond to any alcohol word as demands on cognitive resources (Drobes et al., 1994; quickly as possible,’’ whereas those in the Implementation Sayette and Hufford, 1994), making it more difficult to Intention condition were instructed to say to themselves retrieve and utilize these skills. ‘‘next time I see an alcohol word, I will press the left key as The primary goal of this preliminary study was to quickly as possible.’’ examine whether implementation intentions can facili- Consistent with the Brandstatter et al. (2001) study, we tate action responses to alcohol cues by using a categori- calculated response times to the target (i.e., alcohol category) zation task based on the IAT (Greenwald et al., 1998). and nontarget stimuli (the 3 categories separately). Response An alcohol-specific version of the IAT was used (see times in the prebeverage IAT task were used as covariates Palfai and Ostafin, 2003, for details of the IAT procedure). in each analysis, which was conducted on log-transformed In this task, participants categorize a series of computer- response times. Covariate adjusted mean response times in presented words into 1 of 4 categories (2 target and 2 milliseconds were as follows: Control-Alcohol 5 attribute categories) by pressing 1 of 2 response keys 828 milliseconds (SD 5 181 milliseconds), Control-Placebo 5 as quickly as possible. In this study, the target categories 772 milliseconds (SD 5 167 milliseconds), Implementation- were ‘‘alcohol’’ and a control category ‘‘electricity,’’ Alcohol 5 729 milliseconds (SD 5 164 milliseconds), and and the attribute categories were ‘‘approach’’ and Implementation Intention-Placebo 5 710 milliseconds (SD 5 ‘‘avoid.’’ A congruent and incongruent critical block 113 milliseconds). The 2 (Beverage)Â2 (Strategy) ANC- of trials was presented. In the congruent block, alcohol OVA showed that participants in the Implementation and approach categories were mapped onto the same Intention condition had faster responses to the alcohol- key, such that the same key was pressed when alcohol- related words than participants in the Control condition related or approach-related words appeared on the screen. [F(1, 43) 5 6.39, po0.05]. There was no significant main Performance on this task tends to be faster when catego- effect for the Beverage condition [F(1, 43) 5 0.25, p 5 NS] ries that are associated with each other are mapped and no BeverageÂStrategy interaction [F(1, 43) 5 0.01, onto the same key (e.g., ‘‘alcohol’’ with ‘‘approach’’ for p 5 NS], suggesting that the dose of alcohol was not suffi- alcohol users) compared with when they are mapped cient to cause significant impairments in task performance with nonassociated categories (i.e., incongruent trials). speed. Implementation intentions had no effect on the Eighty trials were presented in the congruent and nonalcohol words [F(1, 43) 5 1.14, p 5 NS], nor did they incongruent blocks. interact with beverage type [F(1, 43 5 0.32 p 5 NS]. Forty-eight participants (19 women) were recruited Thus, the results of this preliminary study suggest that from the community and local universities. Inclusion cri- implementation intentions can increase the speed of emit- teria included AUDIT scores of 81, 21 to 35 years of age, ting a response in the presence of alcohol cues. This a stated preference for beer, and habitual consumption of improvement was observed only for the alcohol words, at least 5 alcoholic drinks per week. Upon arrival at the suggesting that the results were not due simply to a greater lab, participants completed a series of preexperimental focus on the response key. In contrast to previous procedures (e.g., consent form, pregnancy test for wom- studies that have used highly specific targets, the current en), the full IAT, and a series of questionnaires. They were study examined the effects of a more abstract category then randomly assigned to 1 of 4 conditions in the 2 (i.e., alcohol) to explore the utility of implementation 328 WIERS ET AL. intentions. Forming an implementation intention that ence should be considered for application to changing associated an abstract category with a behavioral response addiction-related AB. Examples of these theories are raises the question of whether it is possible to generate provided by Logan and Cowan. Logan (2002) provided a implementation intentions that apply to more generalized general theory of cognition that integrates memory and cues. Utilizing more abstract cues in planning strategies attention under the same general cognitive system. In this might allow for greater generalizability of coping-skills use theory, attention and memory are seen as different mani- across high-risk situations. festations of the same process, 2 sides of the same coin. Clearly, it will be important to replicate and extend these Thus, attention and memory correspond to different ways findings through the use of alternative experimental para- of testing a single process. To Cowan (1988), attention digms and the use of higher doses of alcohol that may effects such as selective attention and, by implication, AB, reliably interfere with cognitive performance. However, the cannot occur without some system for coding perceptions. current study suggests that implementation intentions serve If perceptions are coded, the codes must come from some- as a useful planning strategy to facilitate the use of coping where. His theory postulates that a fast-acting memory skills in high-risk contexts. This strategy may be one of process applies these codes to direct attention. For exam- many planning techniques that increase the efficiency of ple, it is possible that automatic semantic or associative self-control strategies through the use of prospectively link- priming, known to operate very rapidly, may activate ing alternative responses to future high-risk contexts. Other drug-related associations that steer further processing strategies such as imagery encoding and mental simulation (Stacy et al., 2004). Although a type of ‘‘memory bias’’ may also be used to increase the speed of initiation of alter- has been postulated in one useful theory that integrates native responses in addiction-related contexts. attention and memory (Franken, 2003), the bias in that theory occurs after attentional effects. The alternative, COMMENTS fast-acting memory bias should at least be investigated as a reasonable alternative in future research. Addiction Alan W. Stacy theory might also attempt a possible integration of theo- The studies reported here have applied basic research on ries of memory and attention under a single process or at implicit cognition, attention, and implementation inten- least consider the full range of possible memory processes tions to the change of addiction-related cognitions. This that could be involved in attention effects. line of research reflects a growing body of ‘‘translation The other specific comment focuses on associations, research’’ in cognitive science, in which the most consistent broadly conceived. Future research on both AB and findings from basic research are applied to important implementation intentions might consider what associations issues in health. Further, the studies each used indirect apply to the paradigms and findings. For example, can an assessments of cognition, often implicated in either implicit AB for drug stimuli be characterized as an S–R associa- processes or processes that at least are unlikely to involve tion, in which the individual has incrementally acquired a self-report or introspective bias that can plague or con- motor habit of looking toward a stimulus? This would found typical survey measures of cognition. Each of the constitute a different type of association than, for example, studies shows promising findings but also reveals that associations involved in either semantic or affective prim- much more needs to be done in applying basic cognitive ing. Different types of associations in memory are linked research to addiction and other health-related issues. The to divergent neural substrates, having implications for need for more research is not surprising, because these acquisition, activation, and behavior (e.g., Gabrieli, 1998; studies are examples of the beginning of what should Packard and Knowlton, 2002). become a much larger effort. Although several other research Associations are also applicable to the important topic teams have also successfully applied basic cognitive science of implementation intentions. Such intentions, by defini- to this area, this important translation is still only a very tion, involve a triggering situation or cue, to which the small proportion of the research applying cognitive con- intention is relevant. Palfai and Ostafin note the importance cepts to health behavior. Most cognitive research in this of associations in fostering drug use, as well as in interven- area has applied typical survey assessments, metacognitive tions on coping responses. In their study, the use of a test judgments, or concepts from other traditions. Inferences of associations, the IAT, underscores the relevance of based on measures that involve self-perception of one’s associations to implementation intentions. It would be inter- behavior or extensive reflection may have a number of esting and potentially useful to know more about the type serious pitfalls, well summarized years ago (e.g., Feldman of associations that underlie implementation intentions. and Lynch, 1988; Nisbett and Wilson, 1977). Clearly, some linkage is needed between cues and the plans Beyond these general observations, this commentary for action, but it is not entirely clear whether this linkage is focuses on 2 specific issues. Both involve a recommendation best construed as an if-then rule, an S–R association, or for some integration in future research with more general other kinds of associations in memory. Further, the find- theories of cognition. The first recommendation for future ing that abstract concepts (e.g., alcohol) yielded promising research is that several general theories from cognitive sci- results on the IAT suggests that conceptually based asso- CHANGING IMPLICIT ALCOHOL-RELATED COGNITIONS 329 ciative memories are relevant. If so, then a variety of Field’s, Schoenmakers and Wiers’s, and Fadardi and general theories of associative memory could be applied Cox’s AR work, Tibor Palfai and Brian Ostafin taught to implementation intentions. excessive drinkers to use an implementation intention (‘‘to respond as rapidly as possible when I see an alcohol word’’) to reduce their reaction times to alcohol-related GENERAL DISCUSSION words. These promising results suggest that a similar technique could be used in real-world settings to teach W. Miles Cox and Reinout W. Wiers excessive drinkers to increase the speed of a behavioral As stated at the beginning of this article, implicit cogni- response in the presence of alcohol cues. tive processes in addictive behaviors have become an These initial studies on the retraining of addiction- important topic of research. It has been clearly shown that related implicit cognitive processes are quite promising; people who use addictive substances have implicit cogni- they point to exciting possibilities for future developments. tive biases for addiction-related information. The biases Yet, as discussant Alan Stacy pointed out, much addit- have been demonstrated as (a) attentional focus on addic- ional work needs to be carried out to apply basic cognitive tion-related stimuli, of which the person may be unaware; paradigms to addiction-related issues. First of all, the (b) selective retrieval of addiction-related information or cognitive retraining paradigms (or adaptations of them) associations from memory; and (c) selective reactions to need to be tested in clinical settings to determine whether stimuli that reflect the person’s attitudes about, or affective they are effective in helping excessive drinkers and appraisal of, the substance that he or she uses. The cogni- other substance users to change their behavior. Second, tive biases have also been shown to be proportional to the Alan Stacy recommended additional theoretical work, in amount of the substance use. For example, alcohol abusers which researchers test (a) the applicability of general have greater AB for alcohol-related stimulus than heavy theories from cognitive science to changing unwanted drinkers, who in turn have greater bias than light drinkers addictive behaviors and (b) more precisely the nature of (Cox et al., in press). 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