Introduction
Over the last decade interest in craving and desire thinking as core processes in addictive, eating and impulse control disorders has been growing. This is because these disorders, though associated with different desire targets, share similar (transdiagnostic) features, including the compulsion/urge to obtain a given target, the perception of low control over behaviour, and the recurrence of maladaptive behaviours despite awareness of the negative consequences they engender (DSM-IV, APA, 2000). In support of this view, several studies have highlighted the homogeneity of craving processes across appetitive behaviours (e.g. Castellani and Rugle, Reference Castellani and Rugle1995; Field, Schoenmakers and Wiers, Reference Field, Schoenmakers and Wiers2008; Moreno, Warren, Rodriguez, Fernandez and Cepeda-Benito, Reference Moreno, Warren, Rodriguez, Fernandez and Cepeda-Benito2009)
Recent research has suggested that desire thinking may contribute to the escalation of craving. Desire thinking describes a voluntary thinking process orienting to prefigure images, information and memories about positive target-related experience (Kavanagh, Andrade and May, Reference Kavanagh, Andrade and May2005). This style of thinking could be described as a preference (Zajonc, Reference Zajonc1980) or as a reaction to preference awareness. The target may be an activity, an object, or a state (Salkovskis and Reynolds, Reference Salkovskis and Reynolds1994). Desire thinking appears to be transdiagnostic, with subjective reports indicating that this experience is qualitatively similar across a range of targets, including alcohol, food, soft drinks and tobacco (May, Andrade, Panabokke and Kavanagh, Reference May, Andrade, Panabokke and Kavanagh2004).
This definition of desire thinking has at least three implications. First, desire thinking can be considered as a strategy that may be activated to regulate internal experiences of discrepancy between actual and ideal individual state. Second, desire thinking is a conscious cognitive process even if it may be triggered by automatic or implicit processes. Third, desire thinking and its consequences (e.g. incapacity to delay gratification), as well as the mechanisms that activate and control it, may help in further understanding addictive, eating and impulse control disorders (Kavanagh, Andrade and May, Reference Kavanagh, Andrade and May2004, Reference Kavanagh, Andrade and May2005).
The central aim of this study was to explore the mechanisms by which beliefs affect and control desire thinking in individuals with the aforementioned disorders. As a framework for undertaking this we used the Self-Regulatory Executive Function theory (S-REF: Wells and Matthews, Reference Wells and Matthews1994) which conceptualizes multiple metacognitive factors as control components of information processing that affect the development and persistence of psychological disorders. Central to this theory is the idea that a set of metacognitive beliefs are responsible for psychological disturbance by maintaining maladaptive attentional (threat monitoring), behavioural (e.g. avoidance), and cognitive (e.g. worry and rumination) coping strategies. This array of factors constitutes a cognitive-attentional syndrome (CAS; Wells, Reference Wells2000). Metacognitive beliefs refer to the information individuals hold about their own cognition and about coping strategies that impact on it (Wells, Reference Wells2000). Examples of metacognitive beliefs may include: “Worrying will help me cope” or “My thoughts are out of control”. The S-REF theory has led to the development of disorder-specific models of depression, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia (Wells, Reference Wells2008).
In line with a metacognitive conceptualization we hypothesized that desire thinking may be a maladaptive coping strategy similar to rumination and worry and thus a central part of the CAS. We thus predicted that participants would possess both positive and negative metacognitive beliefs about desire thinking. Our aim, in the current study, was to identify the presence and content of such beliefs, examine the nature of the goal of desire thinking, investigate the focus of attention during desire thinking and the impact of desire thinking on craving.
Method
Participants
The sample comprised 24 participants (10 men and 14 women) seeking treatment for desire related problems from the local Mental Health Service of Modena, Italy. Participants were selected from those who had a primary diagnosis of alcohol abuse, bulimia nervosa, pathological gambling or smoking dependence, in accordance with the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV; APA, 1994). Other inclusion criteria were: (1) 18 years of age or above; (2) consenting to the study; (3) understanding spoken and written Italian; (4) absence of co-morbidity diagnosis of either Axis 1 or Axis 2 disorders; (5) no history of having received CBT treatment. The mean age of the sample was 35.4 years (SD = 8.4 years) and ranged from 21 to 52 years. The entirety of the sample was Caucasian.
Materials
Perseveration is the cardinal feature of psychological disorder in the S-REF theory and desire thinking has a perseverative quality. In the S-REF theory metacognitive beliefs and plans for regulating thinking in line with a goal are hypothesized. These factors can be explored using the metacognitive profiling interview (Wells and Matthews, Reference Wells and Matthews1994) as presented below.
Procedure
Following diagnostic screening, participants who met inclusion criteria were asked to consider taking part in the study investigating the experience of desire and associated thinking processes. All participants were interviewed using the metacognitive profiling interview (Wells, Reference Wells2000) adapted to focus specifically on cognitive experiences associated with desire thinking. The interview lasted approximately 30 minutes and was conducted and transcribed by the first author. The tape recordings were independently evaluated by two psychologists on adherence to the interview structure and content of reported responses. The interview attempted to elicit data from the following five areas:
Presence and content of desire thinking. In order to elicit and examine the presence of desire thinking participants were asked to describe a recent episode of desire for the indicated target, by identifying images and thoughts they had when they began to experience desire and how these were actively elaborated. Participants were also asked to identify the trigger of the desire thinking episode.
Metacognitive beliefs about desire thinking. In order to examine positive metacognitive beliefs participants were asked to identify the perceived advantages of desire thinking on their thoughts and sensations, and whether they viewed any disadvantages of giving up the process. Negative metacognitive beliefs were elicited by asking participants about the possible disadvantages of desire thinking on thoughts and sensations, and to consider any advantages of giving up desire thinking.
Goal of desire thinking. Participants were asked questions that sought to identify what was the goal of desire thinking, how they knew when this goal had been achieved, and how the process was interrupted.
Attentional focus during desire thinking. In this section of the interview, participants were asked what the focus of their attention was while they were engaging in desire thinking, and what the advantages and disadvantages were of using their attention in this manner.
Impact of desire thinking on craving. Participants were asked to identify the impact of desire thinking on their craving to achieve the target.
Results
All participants were able to recollect a recent episode of desire thinking. The content of desire thinking included mental images regarding the act of achieving the target and its positive consequences. Verbal content was also present in the form of self-talk regarding the need to achieve the target and self-motivated statements. Participants identified two types of triggers of desire thinking: negative emotions and thoughts (14 participants) and an external target related cue (9 participants).
Twenty-three participants identified positive and negative metacognitive beliefs about desire thinking. Positive metacognitive beliefs concerned the usefulness of desire thinking in: (1) controlling negative thoughts and emotion (17 participants); (2) increasing positive sensations in the form of excitement and motivation (11 participants); (3) increasing executive control over behaviour (6 participants); (4) helping to plan how to reach goals (4 participants). Negative metacognitive beliefs concerned: (1) the damage to executive control over behaviour that may be caused by engaging in desire thinking (16 participants); (2) the uncontrollability of desire thinking (10 participants); (3) the negative impact of desire thinking on self-image (4 participants); (4) the negative impact on cognitive performance (6 participants). The images and thoughts that make up the content of desire thinking and metacognitive beliefs about desire thinking are presented in Table 1.
Table 1. Participants' positive and negative metacognitive beliefs about desire thinking (n = 24)
In response to the question concerning the goal of desire thinking, 14 participants reported using desire thinking to reduce negative emotions and thoughts and 9 to achieve gratification and positive sensations. In response to the question concerning how they knew if their goal of desire thinking had been achieved, all participants reported they did not know. In response to the question on how the desire thinking process was interrupted, 18 participants reported that this occurred only by achieving the desired target and 5 participants reported it was interrupted by some external distracting event.
Participants reported that their attentional focus during the desire thinking episode was continuously shifting between their emotional state and external context. All participants described perceived disadvantages of their attentional strategy, while 11 participants described perceived advantages. Disadvantages concerned the perseveration of desire thinking and craving for maladaptive behaviours, whilst the advantages often seemed directly contradictory to the disadvantages, insofar as they were associated with a reduction of negative emotions and thoughts.
In response to the question about the consequences of desire thinking on craving, all participants reported an increase in the latter.
Discussion
The findings of this study suggest that metacognitions may indeed play a role in desire thinking. The results are consistent with Wells and Matthews' (Reference Wells and Matthews1994) S-REF theory and align themselves to previous findings identifying positive and negative metacognitive beliefs in other disorders (Wells, Reference Wells2008).
Positive metacognitive beliefs concerned the usefulness of desire thinking in controlling negative thoughts and emotion, in increasing positive sensations, in improving executive control over behaviour and in planning how to reach goals. Such beliefs may be involved in the initiation of desire thinking. Negative metacognitive beliefs concerned the uncontrollability of desire thinking, and its negative impact on executive control over behaviour, self-image and cognitive performance. These beliefs may play a role in propagating negative affect once a desire thinking episode has started that may possibly lead to an escalation of the desire thinking process. This would be consistent with the S-REF theory (Wells and Matthews, Reference Wells and Matthews1994), which suggests that psychological disturbance occurs when coping strategies (such as desire thinking) become perseverative.
The main objective in asking questions related to the goal of desire thinking and attentional focus during a desire thinking episode was to elicit information relating to the dynamic of monitoring and controlling this process. The majority of participants engaged in desire thinking as a coping strategy to regulate unpleasant cognitive-emotional states and/or enhance positive ones; they also reported that they did not know if they had achieved their goal. A possible explanation for this is that desire thinking leads to an increase in the sense of deprivation (as the target is imagined but not achieved) and associated lowering mood. This in turn brings to a perseveration in desire thinking because the goal of emotion regulation is never reached. In this respect, desire thinking shows similarities to the process of rumination in depression.
From a therapeutic perspective these findings suggest that the techniques and principles of metacognitive therapy (Wells, Reference Wells2008) may be beneficial in helping patients discontinue desire thinking. The adapted metacognitive profiling presented could help elicit useful information about metacognitive beliefs and metacognitive plans involved in both the initiation and maintenance of desire thinking. Metacognitive beliefs could be questioned and modified using re-attributional techniques (Wells, Reference Wells2008) and the role of desire thinking in internal state and behavioural control could be reviewed. We do not exclude, however, that other metacognitions may be involved in target specific maintenance processes as suggested by previous research in addictive behaviours, for example (Nikčević and Spada, Reference Nikčević and Spada2010; Spada and Wells, Reference Spada and Wells2009).
The results of this study are clearly preliminary and are based on a small sample of individuals with varied diagnoses. The interview was retrospective and hence participants' responses may merely reflect rationalizations of desire thinking rather than beliefs and cognitive processes contributing to it. In addition, a lack of specific measures for desire thinking means that this construct cannot be reliably differentiated from craving. Future studies investigating the role of desire thinking and related metacognitions will require the use of specific measures of both these variables and a disorder specific focus to address these limitations.
Despite these limitations, we believe the present findings provide preliminary evidence that metacognitions may indeed play a role in desire thinking.
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