Behavioral Theory

In contrast to many other methods, behavioral approaches to the treatment of substance abuse have substantial research evidence in support of their effectiveness. Two recent comprehensive reviews of the treatment research literature offer strong evidence for their effectiveness (Holder et al., 1991; Miller et al., 1995). However, some critics argue that this is because behavioral approaches have been developed under controlled conditions and that in "real" therapy there are many more variables at work than can be measured in controlled experiments. Providers should take advantage of the wide range of behavioral therapy techniques that are available. These techniques can be conducted successfully in individual, group, and family settings, among others, to help clients change their substance abuse behaviors.

Behavioral approaches assume that substance abuse disorders are developed and maintained through the general principles of learning and reinforcement. The early behavioral models of substance abuse were influenced primarily by the principles of both Pavlovian classical conditioning and Skinnerian operant learning (O'Brien and Childress, 1992; Stasiewicz and Maisto, 1993). (See Figure 4-1 for definitions of classical conditioning and operant learning.)

Today, behavioral therapy for the treatment of substance abuse disorders is based primarily, though not exclusively, on methods derived from both operant and classical theories of learning. A major tenet of behavioral therapy is that because substance abuse is a learned behavior pattern, changing the reinforcement contingencies that govern this behavior can modify it. This goal can be achieved by focusing on either the classically conditioned craving responses or on the operant reinforcement patterns that are assessed as maintaining the substance abuse. More specifically, the classically conditioned response can be addressed either through extinction or counterconditioning procedures; the operant responses can be targeted through contingency management or coping skills training. (More information about the basic assumptions of behavioral theories concerning substance abuse disorders is contained in Figure 4-2.)

According to behavioral theory, changes in behavior come about through learning new behaviors. Because substance abuse behavior is learned, it can be changed by teaching the client more adaptive, alternative behaviors aimed at achieving the same rewards. Figure 4-3 provides an overview of some of the advantages of behavioral theories of substance abuse and dependence and their treatment.

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By its very design, most behavioral therapy is brief. The aim is not to remake personality, but rather to help the client address specific, identifiable problems in such a way that the client is able to apply the basic techniques and skills learned in therapy to the real world, without the assistance of the therapist. Behavioral therapy focuses more on identifying and changing observable, measurable behaviors than other therapeutic approaches and hence lends itself to brief work. Treatment is linked to altering the behavior, and success is the change, elimination, or enhancement of particular behaviors.

Regular assessment and measurement of progress are integral to effective behavioral therapy. Decisions about the length of treatment are made on the basis of these assessments, rather than according to a formula or theoretical assumption about how long therapy should take. Each individual is approached as a unique case, albeit one to which broad principles can be applied.

Behavioral Therapy Techniques Based on Classical Conditioning Models