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- However, in most substance abuse treatment settings, the prominent features of these three theoretical approaches are merged into a cognitive-behavioral model. Before focusing more specifically on the cognitive-behavioral model, this chapter...
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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...
- 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 Human behavior is largely learned, rather than determined by genetic factors. The same learning processes that create problem behaviors can be used to change them. 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 provides an overview of some of the advantages of behavioral theories of substance abuse and dependence and their treatment. Flexible in meeting specific client needs Readily accepted by clients due to high level of client involvement in treatment planning and goal selection Soundly grounded more 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 Extinction and Cue Exposure Procedures A principal of classical conditioning is that if a behavior occurs repeatedly across time but is not reinforced, the strength of both the cue for the behavior and the behavior itself will diminish and the behavior will extinguish. This principal has been the foundation of behavioral treatments known as "cue exposure" O'Brien et al. Even after relatively long periods of abstinence from substances, being placed in situations that have physical-environmental, social, or emotional cues associated with past substance abuse will elicit strong physiological arousal reactions and reports of strong sensations of craving.
- In cue exposure, a client is purposefully presented with such cues physically e. However, the client is prevented from drinking or taking drugs. This extinction process, over time, leads to a decreased reactivity to such cues. O'Brien and colleagues found that cocaine-dependent clients showed the prototypical arousal and craving responses when first presented drug-related cues that reminded them of their drug use O'Brien et al. Clients then began the cue-extinction protocol. By the sixth 1-hour treatment session, they no longer reported either subjective highs or physiological withdrawal.
- By the 15th session, all clients reported that they no longer experienced craving when presented with the drug-related cues. Clients who received the cue exposure as part of their standard outpatient treatment for cocaine use were also less likely to drop out of treatment and had more cocaine-free weeks than did clients attending the same outpatient program but who did not receive cue exposure. Counterconditioning and Aversion Procedures Another method used to modify behavior according to classical conditioning principles is to make behaviors that had been associated with positive outcomes less appealing by more closely associating them with negative consequences.
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By repeatedly pairing those cues that previously elicited a particular behavior with negative rather than positive outcomes, the cues lose their ability to elicit the original classically conditioned response; instead, they elicit a negative outcome. This has led to the development of what have been described as aversive conditioning or counterconditioning treatment approaches Howard et al. These procedures repeatedly pair negative outcomes with the substance-related cues previously associated with the positive consequences of substance use. For example, the Shick-Shadel Hospital in Seattle uses aversive conditioning techniques with alcohol-dependent clients Lemere, Before a treatment session, the client is asked to drink a warm saline solution and is given an emetic medication that will ultimately lead the client to become nauseated and to vomit. The client is then brought into "Duffy's Bar," a room filled with vivid alcohol- and drinking-related posters, a bar with bottles of a large number and wide range of alcoholic beverages, and other drinking-related cues.School-Based Drug Abuse Prevention: Promising And Successful Programs
The room is meant to highlight and make more salient the cues associated with drinking. The client is asked to identify her favorite type and brand of alcohol. After pouring a drink, she is asked to swirl the alcohol around in the glass, to smell the alcohol, to place the glass to her lips and taste, and then to begin to take a sip of the drink. At that point, as she is about to take a drink, the effects of the emetic drug "kick in" and the client becomes nauseated and vomits. Over repeated sessions, which occur every other day for a day period, the alcohol-related sight, smell, and taste cues not only do not elicit craving and positive feelings about drinking, but rather they now elicit conditioned nausea.- Therapies based on counterconditioning theory typically use chemically induced aversion or electric shock as negative consequences to be paired with the substance-related cues. Visual imagery can also be used in a technique called covert sensitization. In this procedure, the client is asked to imagine as vividly as possible a sequence of events that begin by seeing his favorite bar; this is typically accompanied by increased craving. As the person proceeds further in imagining entering the bar, sitting down, ordering a drink, and so on, the initial sense of craving shifts to mild discomfort. As he visualizes beginning to take a drink and tastes the alcohol, he is then asked to imagine becoming violently sick and vomiting Rimmele et al. While aversive conditioning procedures have most often been used in the treatment of alcohol dependence, they have also been applied to the treatment of marijuana and cocaine use Frawley and Smith, ; Smith et al.
- It should be noted that these aversive conditioning techniques, as well as cue exposure approaches, are best viewed as components of a more comprehensive treatment program rather than as independent, free-standing treatments O'Brien, et al. In this context, Smith and colleagues reported positive outcomes for dependent users of both alcohol and cocaine who received chemical aversion procedures as part of their treatment in comparison to those who did not receive similar treatment Frawley and Smith, ; Smith et al. Rimmele and colleagues also recommended covert sensitization as a highly effective and portable treatment component which, unlike chemical or electric aversion therapies, can be used at any time and in any setting as a self-control strategy Rimmele et al. Behavioral Therapy Techniques Based on Operant Learning Models A number of substance abuse treatment strategies have derived from operant learning principles. While they are often incorporated into broad-spectrum cognitive-behavioral approaches, they have also been used as independent forms of treatment.
- Common elements of behavioral treatments based on theories of operant learning include contingency management, behavior contracting, community reinforcement, and behavioral self-control training. The following sections describe some of the elements used in brief behavioral therapies based on the operant learning model. Contingency Management and Behavior Contracting In contingency management approaches, an active attempt is made to change those environmental contingencies that can influence substance abuse behavior Higgins et al.
- The goal is to decrease or stop substance use and to increase behaviors that are incompatible with use. In particular, those contingencies that are found through a functional analysis see Figure to prompt as well as reinforce substance abuse are weakened by associating evidence of substance use e. Contingencies that prompt and reinforce behaviors that are incompatible with substance abuse and that promote abstinence are strengthened by associating them with positive reinforcers. Box Figure Functional Analysis. A functional analysis probes the situations surrounding the client's substance abuse. Specifically, it examines the relationships among stimuli that trigger use and the consequences that follow. This type of analysis provides more One recent study evaluated the effects of a voucher program in the treatment of methadone-maintained opiate addicts with a history of cocaine use Silverman et al.
- Clients who provided cocaine-free urine samples received vouchers that had monetary value. The value of the vouchers increased as the number of consecutive cocaine-free urine samples increased. Clients in the contingent voucher condition, compared to those who received vouchers on a noncontingent basis, reported decreased craving for cocaine and significantly increased cocaine abstinence.
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A more general positive treatment effect was also noted, with clients in the contingent voucher condition also demonstrating an increased abstinence from opiates. Chutuape and colleagues have also shown that providing methadone take-home privileges contingent on drug-free urine samples among methadone clients with persistent multiple drug abuse resulted in marked reductions in drug use Chutuape et al. Nearly 25 percent of clients in the take-home incentive program met the criterion for marked reduction in drug use and also were significantly more likely to achieve the criterion of having 4 consecutive weeks of drug-free urine samples.- None of the clients in a control condition no take-home privileges met these criteria. Whereas only 2 percent of the control group evidenced a decrease in the frequency of drug-positive urines, clients in the incentive program decreased use between 14 and 18 percent. In addition to increasing drug abstinence, similar voucher systems have been effective in maintaining attendance of methadone clients at a job-skills training program Silverman et al.
- However, in contrast to drug treatment, less evidence is available concerning the effectiveness of such contingency management approaches in the treatment of alcohol problems Higgins et al. Attempts to incorporate real-world contingencies into treatment programs are increasing Higgins, Clearly, programs can build contingencies such as take-home medication privileges into the structure of their programs. Milby and colleagues provide an example of a contingency management system incorporated into treatment that is more relevant to real-life situations of users Milby et al. In this study, homeless substance abusers were enrolled in an intensive day treatment program. A subgroup of these clients was also involved in a contingent work therapy and housing program. Clients involved in the abstinence-contingent program had fewer cocaine-positive urine samples, fewer days of drinking, fewer days of homelessness, and more days of employment during the followup period than those in the standard treatment.
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Naturalistic contingencies may also be useful in treatment. These contingencies include threatened loss of job, spouse, or driver's license and were positively related to treatment outcome among alcohol users Krampen, However, the prognosis was less favorable in those patients who had already experienced a loss in one of those areas because the contingency no longer existed for them. Higgins and colleagues noted that written contracts may be used to help implement a contingency management program Higgins et al. The contract should specify clearly, using the client's own words, the target behavior to be changed, the contingencies surrounding either changing behavior or not, and the timeframe in which the desired behavior change is to occur.- Miczek, Joseph F. Weerts The alcohol-drug abuse-violence nexus presents itself in several distinctly different facets: alcohol and other drugs of abuse may act on brain mechanisms that cause a high-risk individual to engage in aggressive and violent behavior. Individuals with costly heroin or cocaine habits may commit violent crimes in order to secure the resources for further drug purchases.
- Narcotic drug dealers, but not alcohol vendors, practice their trade in a violent manner. Alcohol, narcotics, hallucinogens, and psychomotor stimulants differ substantially from each other and in the way that they are related to different kinds of violent and aggressive behavior. Generalizations about the linkage of alcohol, drugs of abuse, and violence are complicated by the many direct and indirect levels of interaction e. Systematic evidence for alcohol and other drugs of abuse acting on aggression-specific brain mechanisms stems mainly from studies in animals, although a few neuroendocrine and other neurochemical and neurophysiologic measures have been obtained in humans. Data from studies in animals represent the primary means to investigate experimentally the proximal and distal causes of aggressive behavior, whereas studies in humans most often attempt to infer causative relationships mainly by correlating the incidence of violent and aggressive behavior with past alcohol intake or abuse of other drugs.
- It is the objective of the present discussion to consider, integrate, and highlight accounts of empirical data that relate alcohol, opiates, amphetamines, cocaine, cannabis, and other hallucinogens to aggressive and violent behavior, with a particular emphasis on the pharmacologic determinants and potential biologic mechanisms. The major methodological features and the key results of the empirical studies are detailed in tables that appear at the end of this paper.
- The information is organized so that 1 for each drug class, tables for the data on aggression and violence in animals and in humans are separated; 2 the data on human violence are organized according to how they were collected by separating those that stem from criminal statistics, public health records, psychological evaluations, and experimental manipulations; and 3 drug effects on different types of aggressive and violent behavior in animals are grouped according to the aggression-and violence-provoking conditions. Defense of a territory, rival fighting among mature males during the formation and maintenance of a group, defense of the young by a female, and antipredator defense are examples of these types of aggressive, defensive, and submissive behavior patterns, oftentimes referred to as agonistic behavior Scott, Sociobiologic analysis portrays these behavior patterns as having evolved as part of reproductive strategies ultimately serving Page Share Cite Suggested Citation:"Alcohol, Drugs of Abuse, Aggression, and Violence.
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The damaging and injurious consequences of adaptive agonistic behavior exclude-at least transiently-competing individuals from access to important resources. Strikingly, even in the absence of physical injury, among the most severe consequences of being exposed to aggression or the threat of aggression is the prevention of reproductive behavior.- One such example is the so-called psychological castrate monkey who maintains group membership but resides at the periphery, with subordinate access to protected sleeping places, nutritious and palatable foods, grooming interactions, and rest periods. However, the focus on aggressive behavior as it serves an adaptive function in reproductive strategies complicates the extrapolation to violent behavior as it is defined at the human level. How human violence and animal aggression are related in their biologic roots remains to be specified; excessively aggressive behavior may represent an extreme on a continuum with adaptive aggressive behavior patterns. Alternatively, however, adaptive and maladaptive aggressive behavior patterns may differ fundamentally in their functions and causes.
- Particularly during the s, in a different research tradition, experimental preparations were developed that focused on aversive environmental manipulations to engender certain elements of defensive and aggressive behavior in otherwise placid, domesticated laboratory animals. These so-called animal models of aggression relied on prolonged isolated housing or crowding; exposure to noxious, painful electric shock pulses; omission of scheduled rewards; or restricted access to limited food supplies, as the major environmental manipulations Malick, ; Valzelli et al.
- The behavioral end point resulting from such experimental setups rarely extended beyond defensive postures and bites that were difficult to interpret in terms of the ethology of the animal. Such preparations have been questioned in terms of their validity for modeling human aggressive and violent behavior. Similarly, human aggression research under controlled laboratory conditions has employed aversive environmental manipulations that entail the administration of electric shocks, noxious noise, or loss of prize money to a fictitious opponent e.
- Again, this type of experimental aggression research highlights the dilemma of attempting to model the essential features of "real-world" violence under Page Share Cite Suggested Citation:"Alcohol, Drugs of Abuse, Aggression, and Violence. A third approach used to investigate aggressive behavior in animals under laboratory conditions relies on physiologic and pharmacologic manipulations. Histopathological findings of brain tumors in violent patients e. Such experimental manipulations may result in rage-like defensive postures and biting, often called rage, hyperreactivity, or hyperdefensiveness e. Alternatively, electrical stimulation of discrete subcortical regions can evoke predatory attack, as well as aggressive and defensive responses in certain animal species see Delgado, ; Flynn et al.
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