Behavioral Treatments for the Addictions

Description of the Strategy

The behavioral treatment of alcohol and drug addiction has an extensive history, from its humble beginnings emphasizing simple conditioning techniques like aversion therapy to its contemporary emphasis on comprehensive cognitive-behavioral approaches. While recognizing the physiological and genetic aspects of substance use, behavioral clinicians operate under the theoretical notion that addiction is a learned behavior and that treatment techniques based on learning theory can be used to change it.

Behavioral treatment of alcohol and drug abuse typically begins with a functional analysis of behavior, which is, in essence, a complete assessment of the reasons people use and abuse drugs. A thorough functional analysis may take several sessions to complete, and it lays the foundation upon which treatment is built. In determining the patterns of substance use, the counselor inquires with regard to (a) where, when, how much, and with whom does the person use the substance, (b) what triggers episodes of use, and (c) what are the consequences (reinforcers) of use?

The counselor also must determine the expectations of substance use; that is, what effect is expected and desired? Does the person use substances to feel good about himself of herself, alleviate depression, reduce anxiety, combat boredom, reduce cravings, or gain recognition from peers? The functional analysis is not limited explicitly to drug use, but rather examines the skills, strengths, and motivation for change as well.

Self-monitoring is a definite aid to the development of an accurate functional analysis of behavior. In this regard, clients are instructed to keep daily written diaries of cravings and substance use as well as the situations, thoughts, feelings, and people associated with them. To help in this effort, some clinicians ask clients to complete self-rating questionnaires such as the Obsessive-Compulsive Drinking Scale, and others provide clients with handheld computers to record details of addictive behavior.

Once a functional analysis is complete, treatment usually turns toward specific skill development. Coping-skills training can be delivered in a group or individual format, although group delivery is the typical method of choice in most treatment centers. Skills training is based on the notion that substance abuse is a maladaptive way of coping with problems. Skills training provides better methods of interpersonal communication (e.g., appropriate assertiveness), problemsolving skills, and stress management skills. Role playing and assignments to practice these new skills in daily life help to further develop this behavioral repertoire.

Refusal skills training is one of the most common elements of any behavioral approach to treatment. Alcohol and drug dependent individuals are regularly confronted by strong social pressure for continued use. Thus, they are taught not only to assertively reject the substances themselves but also to recognize and avoid the situational environments in which they are found. In this regard, treatment also focuses on the development of new social and recreational activities that are less compatible with substance use.

From a more cognitive framework, treatment entails a discussion of seemingly irrelevant decisions (SIDS). SIDs are small choices that when chained together set the stage for drug use. Each decision by itself may seem minor or irrelevant, but on the whole, the decisions lead the person down a slippery slope of continued drug use. For example, an alcohol-dependent individual may think, “I can go to that picnic and drink soda or something else.” Once at the picnic, that thought may lead to “I can have one beer,” which may then lead to “I can go out with my friends after the picnic.” Each decision, although important in the entire scheme of things, seems irrelevant at the moment. Treatment goals include recognizing, avoiding, and coping with these seemingly irrelevant decisions.

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