Exist Between Alcoholism as a Learned Behavior

¶ … exist between alcoholism as a learned behavior (rather than as a condition arising from any genetic predisposition) and self-esteem. This research is based upon the assumption that there is a direct connection between self-esteem and learned behaviors: While a person's self-esteem may of course be affected by inherited conditions (such as a birth defect) it is much more likely to be affected by conditions that the person believes that he or she has control over. Thus, to the extent that alcoholism is a learned behavior and to the extent that alcoholics believe that their condition is a learned behavior they are likely to suffer from lowered self-esteem for as long as they continue to drink.

Our attitudes about alcoholism have changed dramatically over the last fifty years as our conception of the condition - which causes so much harm and so much grief to so many people, including both the alcoholics themselves and to others - as one that was a matter of complete free will to a question of genetics. That pendulum is slowly swinging back now to viewing alcoholism as a learned behavior, although there is little doubt that there is some element of genetic predisposition to the condition. This research proposes to answer the question of whether the learned aspects of alcoholism are more significant than the genetic elements of it and, if so, how this fact should affect the way in which social workers treat alcoholics and their families.

While it might not seem - to either the alcoholic or those people in his or her circle who are affected by the alcoholics' drinking - that it makes much of a difference as to whether the causes of alcoholism are genetic, learned, or a combination of the two, there are important repercussions in terms of treatment depending upon whether the disease is viewed as inherited or learned. It does little good at all to lecture someone on better eating habits if that's individual's diabetes is caused by genetics. It does a world of good if it is caused by learned behavior. The picture becomes substantially more complicated when there is a mixture of genetic and learned behavioral elements involved.

This research, drawing from the recent work of a number of other researchers, argues that because alcoholism is in large measure a learned behavior it has a substantial negative effect upon the self-esteem of alcoholics who blame themselves for their drinking and - understanding the harm that they are doing to themselves and to those around them - suffer from lowered self-esteem. This would not be the case if the condition were an entirely genetic one: People understand that Tay-Sachs disease has a terrible effect on those around them but they do not suffer a loss of self-esteem because they realize that the condition is in no way linked to voluntary behavior.

The problem statement for this research is thus: If alcoholism is recognized as a learned behavior, what are the effects of alcoholism on self-esteem and how can social workers use learning theories to help alcoholics to become sober? This statement requires us to define several key terms.

Alcoholism: For the purpose of this study alcoholism is defined as a condition that is characterized by drinking of alcoholic beverages that is both habitual (at least two drinks a day) and excessive in that this drinking directly harms the individual physically, psychologically, professionally or socially.

Learned Behavior: Behavior that is acquired through watching the behavior of others and by a Pavlovian system of conditioned response (i.e. A drink produces feelings of pleasure in the individual who drinks more to reproduce those same feelings)

Innate Behavior: This is synonymous with genetically determined behavior. Ascribed behavior is behavior over which we do not have total conscious control. (For example, breathing is an innate behavior. We can stop breathing, but we will only pass out and begin to breathe again. Breathing is not entirely regulatable by the conscious mind.) Genetically-based behaviors may be modified to a much lesser degree than learned behavior

Sober: The state of being no longer physically dependent upon alcohol and of being able to function free of its effects. (For some people this might include some drinking).

Literature Review number of researchers have investigated the question of whether or not alcoholism has a genetic component and, if so, how powerful that component is. This literature review thus looks first at some of the most recent research in this area. In general researchers have found that there is a genetic element to alcoholism but that this element is not as important as the learned-behavior element of alcoholism. After examining the ways in which alcoholism has been determined by a number of researchers to be a learned behavior, this paper will consider the ways in which a deeper understanding of learning theory can help us to come to a model of alcoholism as learned behavior that allows for an effective psycho-social response to alcoholism.

It is important in considering alcoholism as a learned behavior that we understand the nature of learned behavior. We are likely to consider learned behavior vis-a-vis beneficial behaviors: We learn to speak our native language, we learn to do calculus, we learn to play tennis. But research such as that performed by Dawes etal (1999) reinforces the fact that even highly dysfunctional behavior can be learned. Our human brains are programmed to allow us to learn, and there may be some evolutionary bias towards our learning things that are beneficial to our overall survival, but if so this is a slight bias indeed. The ability to learn that is central to our ability to function successfully as human beings cannot be separated from our human ability to learn how to perform actions that are harmful to us. We can learn to take drugs (including alcohol) as easily as we can learn to drive a car.

Our ability to learn to do things that are harmful to us is not doubt exacerbated when there are genetic elements to that form of learned behavior, which may well explain why alcoholism and drug addiction, which are certainly harmful behaviors, are also so widespread. It is difficult for individuals to struggle against the simultaneous pressures of genetics and our human inclination to copy what we see around us.

Hommer etal (2001) suggests that there are indeed genetic elements to alcoholism, although not in an obviously straightforward way (i.e. there is no single gene for alcohol addition). (This research is backed up by other research on addiction such as Atrens [2001] work on nicotine.)

Although the evidence for alcohol neurotoxicity as the cause of gender differences in brain volume among alcoholics is not conclusive, it is stronger than the evidence for pre-alcoholism differences. No studies have examined the brain volumes of children at risk for alcoholism before they begin drinking, and no longitudinal imaging studies of individuals at risk for alcoholism have been conducted. Although there is no direct evidence of smaller brain volumes among individuals at risk for alcoholism, there is evidence that emotional trauma during childhood is associated with smaller intracranial volume and brain volume. Since alcoholic women report a higher rate of emotional trauma during childhood than alcoholic men, it is possible that this could contribute to differences in prealcoholism brain volume. However, we have found that the presence or absence of posttraumatic stress disorder does not influence hippocampal volume among alcoholic women. Further studies are needed to understand the effects of emotional trauma on the developing brain and the adult brain. Genetic influences also may affect pre-alcoholism brain volume.

LeMarquand etal (1999), on the other hand, found a direct genetic component for alcoholism in at least some people. As noted above, however, it is important to recognize that simply because there is (or may be) a genetic element to alcoholism this does not also mean that there is not a strong element of learned behavior.

A substantial proportion of the vulnerability to alcoholism is believed to be genetically mediated, particularly in early-onset, male-limited, type-2 alcoholism. Human and primate studies suggest a significant genetic component in 5-HT-related measures. Additionally, mice with genetic alterations affecting serotonergic neurotransmission show increased aggression and alcohol intake. Environmental factors may also be important. Early stressors lead to greater developmental declines in CSF 5-HIAA in monkeys than in unstressed animals. The extent to which low 5-HT function contributes to the genetic risk for alcoholism remains to be determined. The present results suggest that reduced central nervous system 5-HT function may account for some of the behavioral problems of impulse control that characterize individuals with a multigenerational paternal family history of alcoholism. Whether the propensity for disinhibited behavior after acute tryptophan depletion may help predict future outcome (alcoholism or impulsive behavior or both) remains to be investigated.

Mehrabian (2001) found that the genetic component is likely to be higher when alcoholism is comorbid with other conditions such as depression:

Review of the relevant literature indicates a substantial positive relation between depression and alcohol abuse or dependence (e.g., Merikangas & Gelernter, 1990). A large-scale twin study of women suggests that the substantial co-morbidity between major depression and alcoholism is also a result of genetic factors that contribute to both disorders (Kendler, Heath, Neale, Kessler, & Eaves, 1993).

Aside from showing a shared variance between depression and alcoholism, studies also have shown a possible causal link in the relation between the two to account for part of that variance....Overall, then, findings show that alcohol abuse and dependence on alcohol can be major predisposing factors to depression.

Tomer (2001), on the other hand, suggests that while alcoholism is certainly not rational (i.e. goes against the best interests of the actor in many cases) this does not mean that it is not learned behavior.

There is a widespread belief that addiction, such as alcohol or drug addiction, is a physiological disease. Phelps and Nourse (1986, pp. 7-8), for example, state that "Addictiveness -- the capacity to become an addict to anything -- is a built-in physiological state, something you are born with. Either you are born addictive or you are born nonaddictive." Thus, in their view, the capacity for addiction is a genetic flaw related to carbohydrate metabolism. The research of leading authorities on addictive behavior such as Stanton Peele does not support this view; neither does the model developed here.

Tomer's model has especially relevance for social work because it stresses the importance of an individual's acquiring traits that will allow him or her to act both in terms of self-interest and the common good:

propose a concept of rationality that is essentially the same as the quality Aristotle called virtue (Thomson, 1953). A virtuous person, according to Aristotle, is one who, because of having acquired good habits, regularly makes right choices, choices that leave one with no regrets and that contribute to one's happiness (Adler, 1978, p. 101). An important aspect of virtue is the quality of temperance which consists of "habitually resisting the temptation to overindulge in pleasures of all sorts." Moreover, temperance "enables us to resist what appears to be good in the short run for the sake of what is really good for us in the long run" (p. 103). Virtue requires a mean between excess and deficiency in actions and passions. Quite clearly, addiction is not temperate; therefore, it is not virtuous, and, I would argue, neither is it rational. Rationality in this sense is associated with wisdom and reason, neither of which could be associated with addiction.

Other researchers have also developed findings with important practical and ethical implications for social work vis-a-vis alcoholism, including Rowe & Liddle (2003) who have found that there is a substantial reduction in alcoholism and its related violence with the use of behavioral therapy. (This does not mean that behavioral therapy cannot also be used to help with conditions that have genetic elements):

In 1995, Liddle and Dakof reported that the development of the subspecialty of family-based treatment for adult drug abuse was unfortunately limited. In their review of this area, they concluded that "potential routes of investigation have been neglected (e.g., marital therapy approaches, although present in the alcoholism area, are virtually absent in the drug abuse field); promising lines of work have not been expanded or sustained (e.g., the work of Stanton & Todd, 1982); and the very definition of family therapy for adult addicts has not gone beyond initial conceptualizations" (p. 518). The most encouraging support for family therapy with adult addicts at that time was the program of research of Stanton and colleagues. Stanton and Todd (1982) reported that an innovative and integrative structural-strategic family therapy model reduced drug use more effectively than a family movie condition and standard drug counseling, although no differences were found on vocational or educational functioning. In a subsequent study, this research group showed that a home detoxification program was more effective than standard detoxification for substance abusers (Stanton, 1985).

Running through this research, as through the rest of the research that is being reviewed here is an insistence on addressing the issue of alcoholism as a complex one that in all likelihood includes genetic, behavioral, social and psychological elements.

While most populations seem to be more subject to learned elements of alcoholism than genetic ones, this is may not true for some groups, such as American Indians. However the current state of research is not clear on such issues and more work certainly needs to be done in this subfield, as Akins (2003) notes:

Higher rates of alcohol consumption and problems related to its use among Indians have raised the possibility of a "firewater gene," which supposedly makes individuals of Indian ancestry especially vulnerable to alcoholism and extreme behavior when under the influence (Leland, 1976; Mail & Johnson, 1993). As Duran and Duran note "The myth of the drunken Indian has persisted in this country from colonial times to the present" (1995, p. 95). Indeed, a belief held by many white Americans and American Indians alike is that Indians are "naturally" predisposed to drunkenness and that binge drinking is the "Indian way" of drinking (Caetano, Clark, & Tam, 1998). However, while higher patterns of alcohol use and differences in patterns of consumption may exist for Indians, there is no evidence in the literature to suggest an increased physiological or psychological reactivity to alcohol by Indians as compared to other racial/ethnic groups (Garcia-Andrade, Wall, & Ehlers, 1997; May, 1982).... Given the problems in studies attempting to discover a genetic link to Indian alcohol use, it is likely that studies that examine the cultural, economic, and social circumstances of American Indians may be more successful in explaining their higher rates of substance use.

The correlation between race and alcoholism may simply reflect the correlation between alcoholism and environmental factors (including stress) that Sandler (2001) and Schuckit etal (2001) found:

Several hypotheses have been proposed to explain why a low LR to alcohol might be related to a higher alcoholism risk (6, 7). First, individuals who live in a heavy drinking environment and who seek the same level of intoxication as their peers could be more likely to consume prodigious amounts of alcohol as they search for the effects experienced by those around them. This repeated heavy intake of ethanol could both contribute to subsequent acquired tolerance and increase the probability of spending more time with heavy-drinking friends. Second, for many people the ability to regularly control the intake of alcohol might result from behaviors learned as one compares internal feelings of intoxication with the amount of beverage consumed, a paradigm in which individuals who require much larger volumes of alcohol to have an effect might have more difficulty in adjusting their drinking behaviors to avoid intense drunkenness. In either of these instances, one might predict that the more intense the level of drinking in the surrounding environment, the greater the potential for alcohol-related problems for individuals with a low LR. One such environment could occur among young individuals serving in the military services.

All of these models - which balance genetic elements of alcoholism with learned ones, rely on concepts drawn from social learning theory models. The basic ideas expressed in social learning theory are relatively straightforward; however, scholars have developed highly elaborated models to explain exactly how people learn to respond to complicated social stimuli within their individual environments of complex social systems. The social learning models that inform the kind of model cited above in established a learned element to alcoholism are in turn based upon well-established models of learning including primarily Pavlovian and operant conditioning (or learning). Although these two forms of learning or conditioning (i.e. Pavlovian and operant) are usually classified as different types of learning, it may in fact be more accurate to define them as two different perspectives on the same type of learning, each of which has equally informed the type of social learning model that we are addressing here.

We may most easily see these basic models of learning have implications for the treatment of alcoholism as a learned behavior by beginning with a definition of each of these forms of learning. The model of Pavlovian learning is one of the most famous paradigms in psychology: It is hard to imagine that there is anyone who has not heard the story of how Pavlov taught his dog to associate the sound of a ringing bell, and indeed taught him this so convincingly that after a while his dogs would salivate in anticipation of eating - even when there was only a ringing bell and no food.

Pavlovian learning always works along these lines: An individual (whether a human or a member of a different species) is subjected to a certain stimulus and responds consistently to that stimulus. Pavlovian learning is usually divided into two subtypes, although arguably one of these is not learning at all.

Pavlovian Learning makes use of various types of stimuli and responses to those stimuli. A conditioned stimulus is one that initially has no connection to the response to be learned (a ringing bell means food is on its way = a conditioned response). An unconditioned stimuli is a stimulus that produces the response you want without the animal having to learn it (moving your hand away from fire = an unconditioned response). (http://www.macalester.edu/~psych/whathap/diaries/diariesf96/kai/diary5.html).

It is arguable that such an unconditioned response as moving one's hand away from a fire or putting one's hands out in front of one to keep oneself from falling are not learned at all but inherent or instinctual responses. Responses that are genetically programmed are not, by definition, learned.

Operant conditioning seems at least at first explanation in fact to be a different type of learning because rather than associating a response with a stimulus a response is associated with either a reward or a punishment. While the rewards and punishment usually associated with operant learning are more abstract than the stimuli associated with Pavlovian responses, this does not mean that the two are not fundamentally the same.

Psychologists have for a long time recognized that one of important types of learning (as well as one of the most widespread in both natural and lab conditions) is a process called operant conditioning. This form of learning involves increasing a behavior by following it with a reward (i.e. this increase in the frequency of the behavior indicates that the subject has learned to do it because he or she wants the reward), or decreasing a behavior by following it with punishment (in which case the subject has learned to associate the activity with a punishment). It should be clear that there is an inherent similarity between learning to do something because one hears a bell ringing and learning to do something because one will be given a CD with chamber music on it.

Like Pavlovian learning, operant learning is also usually divided into two different types, those forms of learning that are accomplished through positive reinforcement and those that are accomplished through negative reinforcement. This elements of operant learning are worth defining here because they have clear and important implications for the ways in which alcoholism (when viewed as a learned behavior) is treated:

Operant Learning is the learning of the consequences of your actions, a response/result learning process. There are two ways in which your response can be related to consequence, in a Positive fashion or a Negative fashion.

Within the realms of positive and negative you have Reinforcement (which makes future repetition of a response more likely) or you may have Punishment (which makes the response less likely in the future).

Positive Reinforcement offers some type of reward for the response so as to encourage similar future responses and Negative Reinforcement removes something so as to increase similar future responses.

Positive punishment (i.e. spankings for naughty behavior) supplies the subject with a stimulus that discourages future repetition of a response. Negative Punishment involves the removal of something so as to decrease future repetition of a response (http://www.macalester.edu/~psych/whathap/diaries/diariesf96/kai/diary5.html).

As a further indication that the two forms of learning may be seen as tantamount the one to the other, psychologists have generally found that when used in a positive way (i.e. To encourage improved behavior and/or learning) that reinforcements can indeed be quite successful. However, it should be noted, that when reinforcements are used in a negative way, as when a child is hit or otherwise abused for behavior of which the parent or another adult disapproves) then there is unlikely to be a significant shift in behavior and the results can in fat be emotionally damaging. Thus either models of Pavlovian or operant conditioning can be used to create a treatment model for alcoholism.

In other words, when administered in what psychologists consider "properly" (which means that it is applied in manner that is both consistent and positive), such reinforcement can be used quite successfully to modify behavior as well as to promote learning. Behavior modification and learning can be seen, again, as two different ways of looking at the same thing, for the process of modifying one's behavior because of cues from the environment is in fact what we usually call learning.

The reinforcement technique is often used in clinical settings quite successfully, for example, when a if the subject completes a task in the manner that the experimenter wishes it to be completed, the subject receives a reward, or positive reinforcement. It should be clear how such a model can be used in designing a treatment program for alcoholism; however, such a model of understanding the fundamental process of human learning can also be seen as way in which a treatment methodology can be established for alcoholics outside of a residential treatment program.

If the subject fails to complete the task in the desired way, the subject receives either no reward or is actively punished. This is negative reinforcement and - the psychologist hopes - will encourage the subject to try again to complete whatever the task at hand is according to the experimenter's specifications.

In both this version of learning - which is archetypal operant conditioning - and in the Pavlovian conditioning described above learning occurs through the individual's interaction with the world and the consistent feedback that the individual receives between a particular action on their part and a particular event in their environment.

In other words, alcoholics (in many cases abetted by an underlying genetic predisposition toward addictive behaviors) learn how to drink. They can also learn how not to drink in either a clinical or "home" setting. The fact that alcoholics recognize the learned element of their behavior leads them to feelings of low self-esteem. A program that teaches them to link the action of drinking to feelings of low self-esteem and the action of not drinking to feelings of high self-esteem draws upon basic psychological models of learning to produce a robust model for intervening in alcoholic behavior.

We may be inclined to view operant learning or conditioning and Pavlovian learning as essentially different at least initially because we may tend to view behavioral modification as something as different from learning. It is important to clarify any significant differences that might exist between the two because any lack of clarity in our understanding of how the process of human learning works will have consequences for the effectiveness of any model based on such a fuzzy definition.

All behavior is learned. All new kinds of behavior that result from behavior modification can be seen as the process of learning a new behavior to substitute in the place of an old behavior. This is clearly then a form of learning. Another way of putting this argument is to say that what is called behavior modification is simply learning.

We may find further support for our argument that operant conditioning and Pavlovian or classical conditioning are really essentially the same forms of learning by looking at the ways in which the matching law of operant conditioning (which is formula to correlate behavior with response) with the Rescorla-Wagner model that is associated with predicted the same relationship under conditions of Pavlovian conditioning.

The Recorla-Wagner model is designed to "account for several well-known phenomena of classical conditioning, including the acquisition and extinction of the conditioned response to a simple CS, conditioned inhibition, and phenomena of conditioning to a compound CS." These same phenomena are present in operant conditioning as well (http://users.ipfw.edu/abbott/314/Rescorla2.htm):

The model is as follows:

the current associative value of the CS deltaV = the change in associative value of the CS during a trial.

After each trial, the new value of V will equal the old value of V plus the change in value:

Vnew = Vold + deltaV

The basic Rescorla-Wagner formula shows how V changes during each trial. I'll give the formula first and then describe what the various parameters are:

deltaV = alpha (beta)(lambda - V) (http://users.ipfw.edu/abbott/314/Rescorla2.htm).

Given these definitions, the basic Rescorla-Wagner formula states that the change in the associative strength of the CS during a trial will depend directly on (a) the salience of the CS (alpha), (b) the strength of the U.S. (beta), and - the difference between the maximum associative value of the CS and its current value (lambda - V).

The differences between classical and operant conditioning may in fact lie not in any differences (or in any significant differences in the real world or in the learning patterns or behaviors of the subjects themselves but in philosophical differences among psychologists, who tend to align themselves in either the operant or classical conditioning camps like warriors marching out to battle. Classical and operant conditioning share many of the same basic principles and procedures. For example, Kimble (1961) has pointed out that the basic principles of acquisition, extinction, spontaneous recovery, and stimulus generalization are common to both types of learning. Each of these can be incorporated into a model for the treatment of alcoholism. All of these elements are incorporated into the invention model that is suggested in the research design section that follows.

There are also important implications for understanding the learned component of alcoholism by looking to social learning theory, which emphasizes the ways in which people learn from each other - a point that is often overlooked in more classical models of learning theories. While it is true that we can and do learn some things on our own, it is also true that much of what we learn in done through modeling the behavior of others.

Social learning theory 'posits that people learn from observing other people. By definition, such observations take place in a social setting' (Merriam and Caffarella 1991: 134). Within psychology, initially it was behaviourists who looked to how people learned through observation. Later researchers like Albert Bandura looked to interaction and cognitive processes. One thing that observation does is to allow people to see the consequences of other's behaviours. They can gain some idea of what might flow from acting in this way or that.

Learning would be exceedingly laborious, not to mention hazardous, if people ha d to rely solely on the effects of their own actions to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasion s this coded information serves as a guide for action. (Bandura 1977: 22)

Attending to a behaviour; remembering it as a possible model or paradigm; and playing out how it may work for them in different situations (rehearsal) are key aspects of observational learning (http://www.infed.org/biblio/learning-social.htm).

It may be even more appropriate to discuss alcoholism as a form of situated learning:

more radical model - situated learning - has been put forward by Lave and Wenger (1991). Rather than looking to learning as the acquisition of certain forms of knowledge, they have tried to place it in social relationships - situations of co-participation. As William F. Hanks puts it in his introduction to their book: 'Rather than asking what kind of cognitive processes and conceptual structures are involved, they ask what kinds of social engagements provide the proper context for learning to take place' (1991: 14). It not so much that learners acquire structures or models to understand the world, but they participate in frameworks that that have structure. Learning involves participation in a community of practice (http://www.infed.org/biblio/learning-social.htm).

People - regardless of their genetic heritage - do learn how to drink. And so they can learn how not to drink as well.

Methodology

This research is designed to investigate to what degree alcoholism is learned as opposed to genetic as well as the ways in which the learned part of alcoholism can be unlearned and replaced by newly learned behaviors. This methodology relies on a series of in-depth, open-ended interviews conducted with two groups of individuals, both of which will be recruited from those who have begun to attend local AA meetings within the previous six weeks and so who are therefore all alcoholics by self-definition. Each group will have 10 participants.

In addition to be interviewed, members of both groups will tested with the Rosenberg Self-Esteem Scale, a standard, validated test to determine their levels of self-esteem.

The Rosenberg Self-Esteem Scale (RSE; Rosenberg 1965) is an attempt to achieve a unidimensional measure of global self-esteem. It was designed to be a Gutman scale, which means that the RSE items were to represent a continuum of self-worth statements ranging from statements that are endorsed even by individuals with low self-esteem to statements that are endorsed only by persons with high self-esteem. Rosenberg (1965) scored his 10-question scale that was presented with four response choices, ranging from strongly agree to strongly disagree, as a six-item Guttman scale.

The first item included questions 1 through 3 and received a positive score if two or three of its questions were answered positively. Questions 4 and 5 and questions 9 and 10 were aggregated into two other items that were scored positively, if both questions in the item had positive answers. Questions 6 through 8 counted individually formed the final three items. For the negatively worded RSE questions, responses that expressed disagreement and, hence, were consistent with high self-esteem, were considered positive. Rosenberg (1965) demonstrated that his scale was a Guttman scale by obtaining high enough reproducibility and scalability coefficients (www.mhsip.org/reportcard/rosenberg.PDF).

The scores of the Rosenberg scale will be correlated to the length of the period of alcoholism, the number of drinks the person was consuming, the situations that tend to trigger drinking and the subject's assessment of how she or he first began to drink heavily - information gleaned from in-depth interviews.

After the initial testing and interviews, the members in the experimental group will undergo training in cognitive behavioral therapy. Behavior therapy is an important therapeutic strategy for a number of serious psychological conditions and potentially self-harmful. Because alcoholism is associated with a number of behaviors that may cause distress to both the alcoholic and members of his or her family or friends, the alcoholic may well consider behavioral therapy since the goal of such therapy is to reduce "the suffering of people with mental disorders by changing their behavior patterns" (http://www.realage.com).

Behavioral therapy looks not so much to the causes of a problematic set of behaviors as how to modify them. In this case the client and her family and any professionals who might be involved need to agree which are the most problematic behaviors and establish a hierarchy and schedule of behavior modification.

Behavior therapy, although a relatively new form of therapy, is in fact based on well-established psychological principals, including classical and operant conditioning and social learning. Classical conditioning is a method of learning by association and is one of the most important ways in which people acquire habits; classical conditioning is a well-established method for acquiring or removing a form of behavior. Often alcoholics become afraid of being in certain situations because they have unpleasant or fearful associations with certain locations or situations and have learned to drink in these situations to reduce the anxiety temporarily.

A goal of behavior therapy may be to rid you of a fear-based response to particular events, things, or places by pairing them with a response that relaxes you. The relaxation response will inhibit the development of fear. The more times the event is followed by a relaxation response and not fear, the less likely it is that the event will produce a fear-based response. The fear response is gradually "extinguished." This takes a lot of practice and hard work, but it is a very successful form of therapy (http://www.realage.com).

Cognitive therapy teaches individuals to replace one learned behavior (in this case drinking) with another (in this case not drinking). Given that drinking leads to low self-esteem (which in turn leads to more drinking), breaking the learned response of drinking in certain situations will lead to an increase in self-esteem, which will prove to be a reinforcement for still further reductions in drinking.

Operant conditioning, in which learning occurs as the direct and measurable result of rewards and punishments that a person (or other animal) receives as a result of particular behaviors, is also used in behavioral therapy. The basic idea behind operant conditioning is a very simple one.

If the result of your behavior is a reward, you are likely to repeat the behavior. If the result is a punishment, you are less likely to repeat the behavior. For example, a child reaches for the bright glow at the tip of a match. If she is burned, she may avoid reaching for glowing matches in the future (http://www.realage.com).

Finally, social learning theory can also play a very important role in the behavioral treatment of alcoholics, who are often marked by behavior that marks them as being very different from other people. The imitative aspects of social learning theory can help reduce the types of behaviors related with alcoholics that cause so much distress to both the alcoholic and to others.

This theory stresses that the responses of people in your life, their opinions of you, and, importantly, your opinion of yourself help determine your behavior. The importance you place on the stimuli, the behavior, and the rewards or punishments that may result affect your learning. You may also learn behavior by watching and imitating others (http://www.realage.com).

It should perhaps be noted that the above descriptions address the arena of behavioral therapy, which is an integral part of cognitive behavioral theory but only one part of it. Cognitive therapy - whether joined with behavioral elements or not, assumes as its most central and basic idea the premise that a person's beliefs and expectations as well as his or her cognitive assessments of self, other people, and all aspects of the world around him or her all have an important and even central role in determining how each individual approaches the problems that occur in every life. One's cognitive framework not only determines the ways in which one approaches those problems, in fact, but in no small measure determines how successful one will be in overcoming them (Dalglish etal, 1999).

Alcoholism is in essential ways a disturbance of the cognitive process, producing disorganized and distorted views of the world. Thus a therapeutic approach that allows for a greater degree of cognitive order and a lesser degree of cognitive distortion will be of great help to someone seeking to become sober.

The basic premise of cognitive therapy is that beliefs, expectations, and cognitive assessments of self, the world, and the nature of personal problems in the world affect how we perceive ourselves and others, how we approach problems, and ultimately how successful we are in coping in the world and in achieving our goals. Schizophrenia results in distorted perceptions of the world, including self, and disordered or disorganized thinking. It seems reasonable that a cognitive treatment approach would be helpful in treating schizophrenia, assuming that medication is also employed to alleviate psychotic thought processes which would interfere with any psychotherapeutic interventions (http://www.psychologyinfo.com).

Such a therapeutic approach can easily and effectively be combined with behavioral therapy, which for a number of years been used to treat schizophrenia "usually within a structured psychosocial rehabilitation program, rather than a part of an individual treatment approach" in which behavior therapy seeks to increase those skills that increase an individual's ability to function in the world and "to solve problems as they arise." A combination of cognitive and behavioral therapies can help alcoholics to manage the problems unique to their condition.

These therapies should teach new behaviors to overlay the old behaviors of drinking. After being trained in cognitive therapy techniques (which can be taught in a single session), the subject group will be asked to practice these behaviors. At the end of three months both groups will once again be tested to determine if the subject group has been able to learn new behaviors vis-a-vis drinking more successfully than the control group. The Rosenberg Self-Esteem Scale will again be administered and the subjects will again be interviewed. It is predicted that the experimental group will have increased self-esteem, will be more likely to be sober, and will be more likely to feel few triggers to drink than the control group.