The terms behavioral therapy and behavior modification have been bandied about by many folks, some of whom are poorly informed about them. Unfortunately, in too many facilities the terms have been used so casually and imprecisely that what is being discussed is not correctly termed behavior modification at all. Here we would like to give you a brief rundown of the pertinent factors, as well as point out some of the things that have muddied the waters.
Obviously, any therapy has as its goal the modification of behavior. However, behavioral therapy is the clinical application of the principles psychologists have discovered about how people learn. The basic idea is that if a behavior can be learned, it can also be changed. This can be done in several ways. To put it very simply, one way is to introduce new and competing behavior in place of the old or unwanted behavior. By using the principles by which people learn, the new behavior is reinforced (the person experiences positive results), and the old behavior is in effect “squeezed out.” Another technique is to negatively reinforce (punish) the unwanted behavior; therefore, it becomes less frequent. Recall the discussion of Johnson’s model for the development of drinking behavior in Chapter 6. That explanation was based on learning principles. People learn what alcohol can do; alcohol can be counted on in anyone’s early drinking career to have dependable consequences. Therefore, drinking is reinforced and the behavior continues.
Behavioral therapy is a field of psychology that developed rapidly over the past 20 years. In the course of this development, its techniques have been applied to the treatment of alcoholism. However, the early behavioral approaches fared no better than did other psychological approaches, which were unable to offer by themselves a full explanation of alcoholism, nor alone were sufficient to guide treatment.
Historically, one of the first behavioral methods to be used in alcohol treatment was aversion therapy. In this case, a form of punishment was used to modify behavior. The behavior was drinking and the goal was abstinence. Electric shock and chemicals were the things primarily used. The alcoholic would be given something to drink and as he swallowed the alcohol, the shock would be applied. Alternatively, a drug similar to disulfiram would induce sickness. The procedure was repeated periodically until it was felt that the drinking was so thoroughly associated with unpleasantness in the subject’s mind that the person would be unlikely to continue drinking alcohol. Although short-term success was assured, those results were not maintained over the long haul. Aversion therapy of this form is now used very rarely.
As one author noted in reviewing behavioral approaches toward alcoholism,
Historically there have been many fads in the treatment of alcoholism. … Behavioral therapists have also been guilty of this fad-dism in the form of aversion therapy. There is a recent awareness on the part of behavior therapists that this rather naive approach to a complex clinical problem such as alcoholism is unwarranted.
As the field became more sophisticated, it became clear that an effective behavioral treatment program could not be based on a single behavioral technique. One cannot expect all clients to be successfully treated by the routine application of the same procedure. Just as not all clients are given the same kind and dose of a medication, neither can they be given the same behavioral treatment. Thus, efforts were then made to devise total alcohol treatment programs based on a variety of behavioral techniques.
One such approach received considerable attention and generated much controversy. It centered on efforts by behavioral psychologists in the early 1970s to teach controlled drinking to alcoholics. The Sobells (Linda and Mark) are the researchers most closely identified with this. The initial reports were quite positive. Controlled drinking as an alternative to abstinence seemed to be further supported by several studies that followed up on individuals who had been treated for alcoholism. Though the programs the clients had been involved in were generally abstinence oriented, a portion of these clients (although nowhere near a majority) were found to have returned to moderate drinking without problems. The report that generated the most attention (in part because its findings were released at a news conference rather than being reported in a scientific journal) was the Rand study, funded by the federal government to explore the outcomes of clients in NIAAA-funded treatment programs.
The optimism about controlled drinking as an alternative to abstinence could not be sustained. Several researchers very painstakingly tracked down the subjects of the Sobells’ study to see how they had fared over the long haul. Of the original group, only one was described as continuing as a moderate drinker. All of the others had serious problems and relapses, and four had died of alcohol-related problems. Similarly, Vaillant’s work suggested that once an addictive state has been established, a return to moderate, controlled drinking is very rare. If one follows people over time as he did, the proportion who can maintain a controlled drinking pattern declines. It must also be noted that “controlled” drinking is not to be confused with “social” drinking. Most social drinkers do not need to invest considerable attention and energy to maintain a moderate level of alcohol use.
A recovering alcoholic is likely to face a multitude of problems. One of these is a high level of anxiety. It can be of a temporary nature, the initial discomfort with the nondrinking life, or more chronic if one is the “nervous” type. Whether temporary or chronic, it is a darned uncomfortable state, and the alcoholic has a very low tolerance for it. Many alcoholics have used alcohol for the temporary and quick relief of anxiety. What is now remembered (and longed for!) is the almost instant relief of a large swig of booze. When alcohol or drugs are no longer an option, the alcoholic has quite a problem: how to deal with anxiety. Many simply “sweat it out”; some relapse over it.
Some positive things can be done to alleviate their anxiety, or anyone’s, for that matter. One is relaxation therapy. It is based on the fact that if the body and breathing are relaxed, it is impossible to feel anxious. The mind rejects the paradox of a relaxed body and a “tense” mind. Working with this fact, some techniques have evolved to counter anxiety with relaxation. Generally, the therapist vocally guides a person through a progressive tensing and relaxing of the various body parts. The relaxing can start with the toes and work up, or with the scalp and work down. The process involves first tensing the muscles, then relaxing them at the direction of the therapist. These directions are generally given in a modulated, soft voice. When the client is quite relaxed, it is suggested a soothing picture be held in her mind. The client is then given a tape of the process to take home, with instructions on its use, as an aid in learning the relaxation. With practice, the relaxed state is achieved more easily and quickly. In some cases, the client may finally learn to totally relax with just the thought of the “picture.” Once thoroughly learned, the relaxation response can be substituted for anxiety at will. The response once learned can be used by the recovering alcoholic to deal with those situations in which taking a drink might be almost second nature.
Another behavioral approach to deal with anxiety, systematic desensitization, builds upon the relaxation response. This technique has been found quite useful in treating people with phobias. This is an appropriate approach for recovering alcoholics who may feel panic at the mere thought of a particular situation. We mean real panic, so that even the idea gets them so uptight that the temptation to drink may be overwhelming.
In this process, with the aid of a therapist the recovering alcoholic approaches the situation that leads to anxiety in his imagination. As the anxiety builds up, he is directed to use relaxation techniques he has been taught. Gradually, going step by step, he uses the relaxation to turn off the anxiety, and eventually the situation itself becomes much less anxiety provoking. In alcohol treatment, this approach has been used for persons whose drinking has been partially prompted by stressful, anxiety-producing situations. Given another option, they are better equipped to avoid drinking when such situations arise.
Record keeping is another tool borrowed from behavioral psychology. Not uncommonly, recovering alcoholics may report finding themselves with some regularity “suddenly” in the midst of some kind of troubling situation (e. g., an argument with a spouse), with no idea as to what led up to it. There may instead be periods of inexplicable despondency. Often there is a pattern, but the key elements may not be apparent. Record keeping, a personal log or diary, of one’s daily routine sometimes is used to help identify the precursors that lead up to difficult moments. Recovery requires all kinds of readjustments to routines. By keeping a. daily log, over time, one may have a far better sense of what areas need attention.