Biological
Commentary
Cognitive Training in Addiction: Does It Have
Clinical Potential?
Reinout W. Wiers
Two broad classes of cognitive training can be distinguished
that have been tested as (additional) interventions in addiction
and other psychopathology (1): training of general cognitive
abilities, such as working memory (WM) or inhibition, of which
an interesting example can be found by Snider et al. (2) in the
present issue, and training in which reactions to disorder-
relevant stimuli are trained, different varieties of cognitive
bias modification (CBM). What is the current state of affairs
regarding their effectiveness, and what do we know regarding
working mechanisms and for whom it may work?
Snider et al. (2) did not find overall effects on the targeted
addiction (alcohol use disorder [AUD]), which is in line with
other reports of absence of overall WM training effects on
clinical outcomes in addiction (3–5). Therefore, in this article,
the first reaction to the question above would appear to be a
clear “no.” However, Snider et al. (2) emphasize that the pre-
sent study was not designed as a clinical trial but instead as a
“use-inspired basic research study,” with a focus on cognitive
rather than clinical outcomes [for additional discussion on
experimental studies vs. clinical trials, see (6)]. Furthermore,
they focused on rate-dependent cognitive outcomes, which
implies that the baseline scores are considered in assessing
training effects. One issue with this correlation is that the
change score already contains the baseline score (i.e.,
the outcome score minus the baseline score), and therefore the
use of the Oldham correlation is recommended and the
application of this method in this literature is a step forward.
Despite the overall negative results regarding main effects on
clinical outcomes (2–5), some positive outcomes have been
reported, which suggests that WM training may work for a
subgroup of people suffering from addiction: for problem
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drinkers with relatively strong positive alcohol associations, in
whom an effect was found for WM training on successful
reduction of alcohol use (4), and for AUD patients with strong
delay discounting (who tend to prefer immediate rewards over
larger future rewards), who showed a stronger effect on this
variable (2). This latter finding partly replicated an earlier
finding, where patients addicted to stimulants showed a
decrease in delay discounting after WM training versus control
training (3). In the present study (2), this was further elaborated
by showing rate-dependent WM training effects on episodic
future thinking, which involves vividly imagining future events.
As Snider et al. (2) eloquently phrase it, addicted patients are
often “trapped in a narrow temporal window,” and WM training
may be a way to expand this window, which may ultimately
help to find a way out of the addiction and “remember the
future.”
Why then has no study found overall effects on the clinical
outcome measures for WM training in addiction (2–5)? This
state of affairs contrasts with findings of the other branch of
cognitive training (CBM) in AUD, where several studies in
patients found clinically relevant effects including less relapse
a year after treatment discharge [see (6) for a recent review]. As
noted by Snider et al. (2), a general problem with cognitive
training of the first type (training of general abilities) is gener-
alization. From Thorndike on, the existence of “far transfer” has
been questioned; generalization of training efforts are typically
only found to domains that share features with the trained task
and not in domains that do not (7). I would argue that from this
perspective, the finding that WM training has a rate-dependent
positive effect on delay discounting and episodic future
thinking should be regarded as an instance of close rather than
Figure 1. Different types of cognitive training in
addiction.
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as far transfer (as it is presented here), which would also fit with
the observed overlap in “neural machinery” between WM and
episodic future thinking (2). Given these findings and despite
the overall lack of clinical effectiveness observed, I agree with
the authors that these generalized effects of delay discounting
and future episodic thinking are also promising from a thera-
peutic perspective. WM and episodic future thinking are likely
important abilities needed to successfully curb an addiction;
setting goals incompatible with continued substance use and
vividly imagining the associated desirable outcomes is an
important ingredient of change (8). Furthermore, increased WM
capacity can help to shield these long-term goals from inter-
fering cues triggering short-term goals (e.g., substance cues).
This further raises the question of why the observed increases
in WM and episodic thinking did not result in effects in treat-
ment outcome.
Apart from statistical power issues [the effects of CBM on
reduced relapse in AUD patients were observed in much larger
samples—see (6)], I argue that to make general cognitive
training clinically effective, transfer to the relevant context
needs to be fostered. If you train in chess, you do not get
better in WM or music (7); if a patient’s WM is successfully
increased through training, this is unlikely to directly translate
to effects on abstinence from alcohol or other substances. For
the generalized effects found here on delay discounting and
episodic future thinking (2) to result in clinical effects, the
training could first be related to therapeutically relevant goals.
That would call for future studies aligning WM training with
motivational interventions, such as motivational interviewing
(8), or with other interventions, such as goal management
training: the widening temporal window of the patient should
be used to strengthen long-term goals incompatible with
continuation of the addiction, and with vividly imagining the
associated positive changes.
A second possibility to foster generalization is to link the
training to addiction-relevant cues. Note that when addiction-
relevant distractors are used in the training task, this trans-
fers WM training to a variety of CBM, which typically contains
addiction-relevant (or disorder-relevant) cues (Figure 1). An
alternative is to do general training in conjunction with cue
exposure (9). This is also interesting from a theoretical
perspective, because cognitive training may interfere with
memory reconsolidation of drug memories. In addition, this
may help generalization to the world full of alcohol cues
outside the clinic. This may be further fostered by using
smartphones, which patients can use to engage in a chal-
lenging cognitive task when craving and that may be strate-
gically used in tempting situations. Engaging in a demanding
cognitive task counters memory elaboration of indulging in the
temptation, an aspect of craving. In any case, for general
cognitive training to be therapeutically effective, it seems
crucial to foster connections to therapeutic goals so that the
widened therapeutic horizon established by the training is
indeed used for therapeutic purposes.
One other issue regarding the clinical application of cogni-
tive training concerns its repetitive and rather boring nature.
Making training adaptive [as in the experimental conditions of
the studies testing WM training in addiction (2–5)] can partly
counter this problem. However, relating training to therapeutic
goals (as sketched above) and/or including addiction-relevant
102 Biological Psychiatry: Cognitive Neuroscience and Neuroimaging February 2018; 3:101–102 www.sobp.org/BPCNNI
Commentary
cues would make the training more therapeutically meaning-
ful. Moreover, providing patients with feedback on their neu-
rocognitive improvements can have further motivating effects.
Finally, cognitive training could also be combined with
neurostimulation (10), with transcranial direct current stimula-
tion being the most accessible variety for clinical purposes, for
which increases in WM and decreases in craving have been
reported (10). But like WM training and CBM, it appears to be
crucial to combine these interventions with general therapeutic
interventions that use the increased capacity to disengage
from the temptation now to achieve therapeutic goals and
remember the virtues of a future without drugs.
Acknowledgments and Disclosures
I thank Professors Hilde Huizenga and Han van der Maas for sharing their
perspective on Oldham’s correlation.
The author reports no biomedical financial interests or potential conflicts
of interest.
Article Information
From the Addiction Development and Psychopathology (ADAPT) Labora-
tory, Department of Psychology, University of Amsterdam, Amsterdam, The
Netherlands.
Address correspondence to Reinout W. Wiers, Ph.D., University of
Amsterdam, Psychology, Postbus 15916, Amsterdam 1001 NK, The
Netherlands; E-mail: r.wiers@uva.nl.
Received Dec 22, 2017; accepted Dec 22, 2017.
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