Applications to Addiction Counseling

As stated in the outset of this chapter, one can learn addiction through classical and operant conditioning. The observational approach indicates how modeling can lead to maladaptive behavior. The cognitive approach shows how thinking influences behaviors and emotions. Once one learns “addiction,” one must unlearn it (extinction). So how does all this information translate into clinical practice?

In working with clients, it can be helpful for the counselor to know about classical and operant conditioning so that you can teach the client about the conditions and responses that reinforce their behavior. While you might not go into depth with the terminology with a client, you can teach them about the conditions and contexts that help them maintain their drug-taking behaviors (e.g. reinforcers, conditions and contexts). For example, a client tends to gamble when he is with his friends at a casino. The two conditions, with his friends and at a casino, trigger his gambling.To extinguish this learning, he must not associate friends and casino with gambling. Therefore, he may want to remove himself from the context of casinos and stay away from friends with whom he gambles.

With operant conditioning, a counselor can work with a client on finding new reinforcers (e.g. exercise over stimulants) to change what is rewarding to him/ her. One prominent approach is to use contingency management to work with clients (CSAT, 1999). Contingency management involves rewarding clients for

Figure 3.1 Behavioral Contract Example

positive behaviors, such as abstinence (NIDA, 2012, p. 45).This involves targeting a behavior, analyzing the environmental cues that control the behavior, modifying the environmental events, and measuring the behavior change (Thombs & Osborn, 2013).

Similar to contingency management are behavioral contracts. A behavioral contract could include the targeted behavior to change, the rewards or reinforcements for incremental changes, and dates (see Figure 3.1). Behavioral contracts are often used with criminal justice clients (NIDA, 2014).

In the 1990s, there was research that used voucher-based treatment for cocaine dependence. Clients who were abstinent from cocaine earned vouchers which they could use for retail (with the counselors approval) (Thombs & Osborn, 2013).The results indicated that those who participated showed better program retention than those who did not participate in such a program.With better retention there are better outcomes (Thombs & Osborn, 2013).

Another approach based on operant conditioning is the community reinforcement approach (CRA) (CSAT, 1999). CRA weakens “the influence of the reinforcement received by substance abuse and its related activities by increasing the availability and frequency of reinforcement derived from alternative activities, particularly those vocational, family, social and recreational activities that are incompatible with substance abuse” (Higgens et al., 1998 in CSAT, 1999, pp. 57— 8).The combination of community reinforcement and vouchers has been shown to be effective (NIDA, 2018).

With observational learning a counselor may suggest that a client attend at 12 Step or other group meeting to “observe” and learn from those who are in recovery from gambling or stimulant abuse. Another form of observational learning in this context, is the role of a sponsor. The client can learn from observing his/ her sponsor.

Table 3.1 Cognitive Distortions

thoughts to replace such distortions.This in turn, impacts behavior. I think better, therefore, I behave better. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a resource for counselors that describes CBT among other brief therapies in the TIP (Treatment Improvement Protocol) 34: Brief interventions and brief therapies for substance abuse (CSAT, 1999).

Another approach is RET (Rational Emotive Therapy). “RET concentrates on peoples current beliefs and attitudes and self statements contributing [to] or ‘causing’ and maintaining their emotional and behavioral disturbances” (Ellis, McInerney, DiGiuseppe, & Yeager, 1988, pp. 1—2). Ellis and colleagues would say that we do experience negative life events but these are not what leads to negativity in our lives. It is how we think about the event that leads to negativity. In order to help clients, RET therapists help them identify the ABCs. That is, the counselor helps the client identify the Activating (or adverse) event, the irrational Belie], and the Consequences. In identifying the activating event, the counselor and the client examine the situation which led to the irrational belief. The irrational belief tends to be rigid or extreme; inconsistent with reality; illogical or nonsensical; and lead to negative consequences (Dryden & Neenan, 2004). In addiction, the activating event could be preparing for an exam or test. The irrational belief might be “I can’t cope with this stress. I have to have a cigarette to relax.” The consequence could be smoking a cigarette. A counselor and client would then substitute the irrational belief with a rational one, such as “Yes, this is stressful but I have done well on exams before. I can do some deep breathing exercises,” which would lead to a healthier response to the activating event.

Another approach used to help with alcohol and other drug problems in relation to negative thinking and maladaptive behaviors is SMART recovery. SMART recovery is an alternative (or an addition to) 12-Step programs. It is a program that teaches people how to change self-defeating thinking, emotions and actions, and to work towards long-term satisfactions and quality of life (SMART Recovery, 2018). It incorporates principles of RET and CBT through self-help meetings and materials.

Another area that uses behavioral and cognitive terms is relapse prevention. Many times counselors will help a client identify what behavioral (going to the park) and cognitive (thinking I must smoke to keep my friends) experiences that “trigger” his/her craving to use. Once these are identified, the counselor and client would identify healthier behavioral activities and cognitive strategies to deal with triggers and cravings.

• [1] 2 will never have fun”),“the cognitive distortion” (e.g. overgeneralization) and the “healthier response” (e.g. “When I didn’t drink I did have fun, I just have to find fun things to do again”). One of the more effective counseling approaches for addiction is cognitive behavioral therapy (CBT) (McHugh, Hearon, & Otto, 2010). Using principles of cognitive and behavioral approaches, CBT focuses on distorted cognitions and maladaptive behaviors. In this type of therapy, a counselor would help the client identify irrational, distorted thoughts or beliefs that lead to unhealthy behaviors. Additionally, with the cognitive distortion list (Table 3.1), the therapist and client can identify what type of distortion the client experiences and find healthier