Friday, April 13, 2012

Penny for [a significant change in your behavior]?

       The first type of behavioral treatment I am going to compare to cognitive behavioral therapy (the prevailing "gold standard" in the treatment of substance abuse disorders) is that of contingency management. In this type of treatment, patients are challenged to achieve a specific behavioral goal (for example, abstinence from a drug of abuse for a specified period of time, as verified by drug urine drug tests performed according to an agreed-upon schedule). This type of behavior modification is based upon principles of behavioral pharmacology and operant conditioning (a type of conditioning in which an organism acts, or "operates" on its environment in a manner that elicits particular positive or negative results) (Carroll & Onken, 2005). The crucial link between contingency management and operant conditioning is the idea, first publicized by Edward Thorndike, that organisms learn something called the "law of effect"- the idea that certain actions lead to desirable results and others to undesirable ones- and that humans, just as laboratory rats and other animals tend to do "what works"- essentially, whatever it is that might help them to obtain the positive results they desire (Cherry 2012).
In the context of contingency management, the hope is that the law of effect (Cherry 2012) would encourage an individual in need of treatment to abandon the previous, maladaptive behaviors in favor of pursuing the rewards offered by the contingency contract largely because "it works;" the rewards offered are significantly more rewarding than continuing to suffer from one's drug dependence.
       Some might argue that drug addicts aren't actually "suffering" from their addictions, and that perhaps they even find their regular drug use pleasant and enjoyable- and that, thus, contingency management would not be an effective means of combating substance abuse, because substance abuse would already be so rewarding in itself that an alternate reinforcing stimulus would have trouble competing with it (Carroll & Onken, 2005).  This view, however, is contradicted by the evidence. In fact, Solomon and Corbit, in their Opponent Process Theory of Motivation (as cited in Domjan 2009), found, among other things, that "... intense emotional reactions are often biphasic. One emotion occurs during the eliciting stimulus, and the opposite emotion is observed when the stimulus is terminated" (Domjan, 2009, p. 59). The evolutionary function of such rapid reversals between affective states would be to keep the human psyche on an "even keel," (Domjan, 2009, 59) in order to allow for maximal processing of important stimuli and optimal problem-solving (Domjan 2009). In the case of drug use, the authors of the study argued, an initial positive state (dominated by what was called an "a process") (Domjan, 2009, p.60), would inevitably later be followed by a equally-intense negative affective state (called a "b-process") (Domjan, 2009, p.60). Over time, (as, for instance, a casual drug user became a full-fledged drug addict), the initial, pleasurable "a-process" (Domjan, 2009, p. 60) (or "high) is followed more rapidly and overcome more completely by the unpleasant "b-process" (Domjan, 2009, p.60). Over time, the effects of the pleasurable a-process (Domjan, 2009, p.60) would be dulled by the buildup of drug tolerance- while the b-process (Domjan, 2009, p.60) would only become increasingly noxious and pursue the a-process (Domjan, 2009, p.60) ever more closely, dominate over its effects ever more noticeably, and linger for increasingly longer periods after the effects of the a-process will have worn away (Domjan, 2009). The cumulative effect of this, according to Solomon and Corbit's theory, would be that drug addicts would eventually gradually transition from having their motivation for drug use be the pursuit of a pleasurable "high" all the way to seeking to pursue the use of drugs simply as part of an effort to dull the debilitating discomfort the b-process (Domjan, 2009, p.60) (or hangover/ withdrawal effect) was causing them (Domjan, 2009). From this, it becomes clear that using a drug, for a substance abuser with an established habit, quickly becomes less and less enjoyable, and is in fact likely to become more of a compelling physiological need and chore than any sort of pleasure over time (Domjan, 2009). Thus, the offer of a reward or other incentive for abstinence, in combination with the offer of free treatment (an opportunity to rid oneself of a habit that, over time, may have become debilitatingly demanding!) may indeed appear to be a very enticing offer to those motivated to rid themselves of an addiction!
       Such a conclusion is also warranted based on empirical evidence; a study by Miller, Klahr, Gold, Cocores, & Sweeney (as cited by Budney, Higgins, Delaney, Kent & Bickel) which investigated "common reasons given for the use of cannabis by persons presenting for cocaine treatment" (Budney et al., 1991, p. 657) concluded common motivations cited by cocaine addicts for their comorbid use of cannabis included: "(a) to counteract cocaine-induced anxiety (b) to relieve cocaine-induced depression (c) to substitute when cocaine is scarce and (d) to use as a primary drug of choice" (Miller et al., as cited by Budney et. al, 1991). The fact that three out of four of the motivations for the use of an entirely separate drug (with all of the costs and possible legal problems the use of an illicit substance would entail) were simply to counteract the negative effects of another illicit drug provides an all-too-vivid illustration of the previously-mentioned opponent-process theory (Domjan, 2009) in action!
       Furthermore, the fact that these individuals were fully aware of the nature of their motivation for using cannabis (as evidenced by their ability to cite clear reasons for doing so), and the fact that they readily admitted that they weren't using it so much for pleasure it might afford them, but rather to counteract the negative effects of cocaine (an idea that doesn't necessarily make much logical sense- "why create for yourself a whole host of legal and possible financial and health problems by introducing another illegal substance into your body to counteract the effects of a first one, instead of simply quitting them both? Isn't such an action, in real of drug addiction, very similar to the irrational phenomenon, of "robbing Peter to pay Paul" in the financial one, with both making very little rational sense?) in itself serves as evidence (albeit indirect evidence) that they don't need the insight into their own thinking and irrational thoughts that cognitive behavioral therapy might provide; rather, it would appear that such individuals would benefit far more greatly from being a part of an organized, systematic behavior-change system; they already know their reasons for making the decisions that they do, and that, for the moment, these are somewhat irrational; the facts just simply don't add up. What they need is help modifying them.
       A particularly promising means of modifying the maladaptive behavior pattens associated with drug abuse seems to be that of a combination of contingency management and what Higgins, Delaney, Budney, Hughes, Foerg, and Fenwick (1991) called a "community reinforcement approach" (Higgins et al. , 1991, p. 1218), the essential idea being a comparison of treatment outcomes (as measured by retention in the treatment program and abstinence from drug use) between a traditionally-used 12-step program and a new approach which combined contingency management and maximizing the patients' participation in their communities, through such means as obtaining and holding down jobs and socializing with friends and neighbors. Not only did the results of their study indicate that the participants involved in the more community-oriented approach did indeed have a greater rate of staying in the program (Higgins et al. 1991), but such a method of intervention also effectively responds to an important criticism that has to date been fired at contingency management as a method of therapy- that of it being overly focused on material gains, which are expensive for therapists and other service providers to supply, and which can't be provisioned indefinitely (Carroll & Onken, 2005). The community resource approach focuses a patient's attention away from such short-term, material gains, and onto rewards- like forging and sustaining lasting friendships and the independence which having a decently-paying job can afford one- which are "rewards" in and of themselves and can last for a lifetime. (Higgins et al. 1991). 
       Another factor which makes such a "modified contingency-management program"(Higgins et al. 1991) more effective is the fact that it relies upon what is called an "variable ratio schedule of reinforcement"(McIntyre, 2002) that is, a reinforcement schedule where a particular behavior (for instance, abstinence from a particular illegal substance, as evidenced by negative urine test screening results) is rewarded when a particular number of desired responses has been generated- but when the participant has no idea of the exact number required or of when the reinforcing stimulus will occur. This type of reinforcement schedule- an example of operant conditioning in action- is also used by casinos for their slot machines, in the expectation that a participant will continue playing the slots for as long as possible in the hopes that "this draw will be the one" (i.e., that "this" specific response- here, input of money- will be the one to trigger the jackpot reward) (McIntyre, 2002). Such a reinforcement schedule will also eliminate the need for giving rewards for each instance of the desired behavior separately- saving service providers a significant amount of money!
   Thus, given the benefits- specifically, those of focusing in on problem behaviors and their modification, rather spending time focusing on patients' maladaptive thought patterns- which the Budney et al. (1991) case study of two cocaine addicts has shown to be not nearly as crucial for the maintenance of a particular behavior as a desire to eliminate strong, physiologically-rooted cravings, and the effectiveness of contingency management, especially when combined with the community research approach mentioned in the Higgins et al. (1991) study, contingency management combined with a community resource approach seems to be a more effective means of therapy for drug addiction than the cognitive behavioral therapy commonly used at this time.

Budney, A. J., Higgins, S. T., Delaney, D. D., Kent, L., & Bickel, W. K. (1991). Contingent 
                         reinforcement of abstinence with individuals abusing cocaine and marijuana. Journal of 
                         Applied Behavior Analysis, 24(4), 657-665. doi: 10.1901/jaba.1991.24-657. Retrieved 

Carroll, K. M., & Onken, L. S. (2005). Behavioral therapies for drug addiction. The American Journal   
                      of Psychiatry, 162(8), 1452-1460. Retrieved from

Cherry, K. (2012). What is the law of effect?. Retrieved from 

Domjan, M. (2009). Learning and behavior. (6 ed., pp. 59-60). Belmont, CA: Wadsworth, Cengage 

Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Fenwick, J. 
                        W. (1991). A behavioral approach to achieving initial cocaine abstinence. The American 
                        Journal of Psychiatry148(9), 1218-1224. Retrieved from 

McIntryre, T. (2002, January 4). Schedules of reinforcement. Retrieved from 

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