Behavioral Techniques for Substance Abuse

Kyle is a 42-year-old, single, Caucasian male, with 16 years of education. He works as a software programmer. Kyle reports that he is seeking assistance in helping to "kick his drinking problem." Kyle explains that his use of alcohol has gotten progressively worse over the last five years. He explains that he began drinking as a teenager in high school, but then only occasionally. He never felt that his drinking was problematic until he returned from the service and in the last five years it has gotten worse. He began drinking more regularly following his deployment in the Gulf War. As a reservist in the U.S. Marines Kyle served in Iraq and while on a weekend leave just before he was sent back to the United States Kyle was exploring a rural marketplace with several military colleagues. A bomb detonated at the market killing several dozen local civilians and one of Kyle's colleagues. Kyle, who was not hurt in the blast, heroically assisted both his colleagues and many of the civilians who were critically wounded. Kyle does not experience any significant PTSD symptoms associated with this event such as flashbacks, dreams, etc., but noted that he began regularly drinking "socially" regularly as an effort to deal first with the anxiety associated with his military experiences and later to relieve the minor stress from his work.

Kyle now goes to a local tavern every evening following work, has dinner, and then stays at the tavern until 8:00 or 9:00 PM every weekday evening drinking beer and socializing. He returns on Saturdays in the afternoon drinking until closing time. He reported that his drinking initially helped him deal with the stress and anxiety of his job, but that he recently was arrested twice for impaired driving and has been having issues at work related to his being "sluggish" following the prior evening's drinking. He denies experiencing blackouts or other physical withdrawal symptoms.

From a classical conditioning perspective (CC) one could view Kyle's experience of anxiety as an unconditioned stimulus that was originally perceived as threatening during his experience in the Gulf War. His response to this physical discomfort was to use a central nervous system depressant, alcohol, to relieve his anxiety and stress. Whenever Kyle experienced this anxiety or stress he repeated this behavior. Later, when experiencing stress and anxiety in the work environment Kyle took to visiting the local tavern and found a relief for this physical discomfort. He initially went to the local tavern occasionally; however, the environment of the tavern and all of the cues there may have also served as a conditioned stimulus that may have resulted in his experiencing less discomfort from the stress and anxiety at work, thus he now goes to the tavern daily whether he is stressed or not. Kyle could benefit from any of the several types of therapies are based on CC principles. Two are cue exposure therapy and aversion therapy.

Cue exposure therapy (Drummond, Cooper, & Glautier, 1990) interprets cues associated with substance abuse (in this case the stress at work and the sights, people, and all environmental stimuli in the tavern) as conditioned stimuli. By having Kyle experience repeated exposure to the cues without engaging in the substance abuse the effect of the cues could be extinguished. This would probably be best using imagery-based exposure therapy with relaxation to learn to handle the stress and then having him attend the tavern with someone else who would make sure that he didn't drink while he was there. Over time he would not associate the conditioned stimulus with the conditioned response. Of course another way would be just have him stop going to the tavern altogether (but we still need to address his stress). However, it is never possible to identify all the cues associated with a conditioned behavior and over time the behavior could spontaneously remit is Kyle continues to experience stress at work and/or go to the tavern.

Aversion therapy (O'Farrell et al., 1992) intentionally cares an association between an unwanted or dysfunctional behavior and an unpleasant experience. In this case we could have Kyle take a drug such as Antabuse that will result in him becoming nauseous when he drinks alcohol. Theoretically this will reduce his alcohol consumption. However, there are issues with this method as well. For instance, the noncompliance rate with drugs like it this is quite high and the effects of aversion therapy dissipate rather quickly once the drug is discontinued (O'Farrell et al., 1992).

One way to look at Kyle's substance abuse is through an instrumental conditioning (IC) paradigm. Kyle's use of alcohol can be viewed as a form of negative reinforcement where drinking alcohol relieves the unwanted symptoms of stress/anxiety (Wagner, 2001). If Kyle can be taught a more productive way of dealing with stress and anxiety he will not need to use alcohol. This could involve pretty much the same process as mentioned earlier by using guided imagery to teach Kyle more productive coping techniques to deal with his stress such as relaxation, rhythmic breathing, etc. In this case, changing the antecedents and consequences associated with his substance abuse (using these techniques when feeling stressed and as opposed to going to the tavern) would decrease the unwanted behavior. In addition, the consequences of his behavior could be addressed. For instance, instead of going to the tavern following work he could go to a yoga class or some other productive activity where he would socialize with others and achieve positive benefits that are also achieved at the tavern, but in this case he would be dealing with stress and would still be getting the other reinforcements he experiences at the tavern (e.g., socialization, companionship, etc.). Moreover, sanctions imposed by the legal system for his impaired driving are designed to act as punishments to decrease this behavior. Issues here include the notion that there is a lot of change involved and it has been long understood that people are resistant to changing things that work of them (e.g., Cartwright, 1981; Wagner, 2001) and that punishments need to be imposed immediately to be effective, whereas the legal system takes some time to do this (Wagner, 2001).