A behavioral approach to drug abuse

Drug and Alcohol Dependence, 5 (1980) 5 - 25 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands

5

Review Paper

A BEHAVIORAL

K. GLJNNAR

University LENNART

APPROACH TO DRUG ABUSE

G@TESTAM

of Trondheim

(Norway)

MELIN

University

of Uppsala (Sweden)

(Received

January

18,1979)

Contents Introduction. ............................................... Behavioral psychology ....................................... The problem of design ....................................... Drugabuse ............................................... A behavioral view of drug abuse. .................................. Sources of reinforcement ..................................... Acquisition and maintenance factors. ............................. Individual behavioral techniques. .................................. Treatment of the drug-taking behavior. ............................ Aversion therapy. ........................................ Extinction ............................................. Treatment of alternative behaviors ............................... Desensitization and relaxation ................................ Assertiveness training. ..................................... Covert conditioning. ...................................... Contingency contracting. ................................... Broadspectrum approaches. ................................. .................... Wardprograms.........................: Conventional ward structure ................................... Program 1: Introduction of activities and rules ....................... ................ Program 2: Flexibility between activities and reinforcers. .......................... Program 3: Stepwise access to reinforcers. Program 4: Increased flexibility between activities and reinforcers plus sustained activity ............................................... ........................... Comparison between the ward programs ........................ Outline of a behavioral program for drug abuse. A token economy frame. ..................................... Individual behavior analysis. ................................... Decreasing the drug-taking behavior .............................. Increasing alternative behaviors ................................. Training to cope with stress etc. ................................. Changing the social situation ................................... Contingency contracting. ..................................... Regular patient conferences. ................................... Discussion.. ............................................... References. ................................................

6 6 6 7 8 8 8 9 10 10 11 11 11 11 11 12 12 12 12 13 14 15 16 17 17 20 20 20 20 20 21 21 21 21 23

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Introduction Behavioral psychology During the last fifteen years there has been a rapidly growing interest in what is known as operant psychology originally developed by Skinner (1938). One of the main reasons for this growing interest is that operant principles are easily applied and that they are an integral part of behavior modification or behavior therapy. This particular kind of technology has been applied to most areas of psychopathology with quite promising therapeutic results (O’Leary and Wilson, 1975). The operant approach is based on the assumption that most human activities are learned. The therapist applying operant principles is mainly concerned with: (a) the relationship of the person to the environment, (b) the question of how behavior originates and changes as a result of personenvironment interaction, (c) the necessity for specifying reactions as observable behaviors, (d) the necessity for describing measurable aspects of situations, and (e) the necessity of constructing reliable measures for detecting change (Levy, 1970). In the field of abnormal behavior this perspective has placed mental illness and psychiatric problems in a new light. The person’s problems are not seen as a sign or symptom of some more fundamental underlying process, but as behaviors worth changing per se. The development of these problem behaviors is not seen as qualitatively different from other types of behavior, but rather as the result of other reinforcement contingencies (Krasner and Ullman, 1973). Thus, the goal of the behavior intervention is to alter overt behavior. Not only has the efficacy of this perspective been convincingly demonstrated (Leitenberg, 1976) but also such efforts are corroborated by substantial research findings from the field of social psychology where behavior has been shown to be changeable without any attack on inferred underlying dispositions (Burgress and Bushell, 1969). In behavior therapy, assessment of behavior, implementation of a treatment program and evaluation of the results are closely interrelated. For clinical purposes the most important question to be answered is whether the therapeutic intervention has resulted in change in the target behaviors. Scientifically it may also be of interest to determine the functional relationship between the target behaviors and the therapeutic program. A functional relationship is demonstrated when a change in the experimental condition or contingency of reinforcement results in a systematic change in behavior. The problem of design The major obstacle to the development and evaluation of therapeutic interventions in clinical psychology and psychiatry has been the difficulty of conducting meaningful clinical research (Barlow and Hersen, 1973; Hersen and Barlow, 1976).

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The traditional experiment-control group or intersubject research has not readily lent itself to research on clinical and therapeutic problems. Matching large groups of patients with similar problems or symptoms is often very difficult if not impossible. Withholding treatment from the control group, even if treatment is eventually implemented, presents an ethical dilemma. Researchers in the field of operant conditioning have generally used another type of experimental design to determine whether a given intervention is responsible for behavior change: the intrasubject design. In this design the performance of an individual or group of individuals is compared across different conditions over time. Behavior of the individual or group is assessed under two or more conditions. The rationale behind this design has been thoroughly described by a number of authors: Baer (1971), Baer et al. (1968), Bijou et al. (1968), Sidman (1960), Thoresen (1972), and Wolf and Risley (1971). In short, the basic logic of this design is to determine operations functionally related to the performance of a certain behavior (Kazdin, 1973). The intrasubject design offers several major advantages for applied clinical research: (1) Since each patient or unit serves as its own control in any given experiment, effective treatment can thus be linked to specific characteristics of immediate relevance to the clinician. (2) The size of the behavioral change is readily observable, which facilitates judgement of clinical usefulness. Data can be statistically analyzed, but this is often not necessary. (3) Therapeutically active ingredients in a composite treatment program can easily be singled out. (4) In an intrasubject design where measures are recorded continually, the researcher has the opportunity to observe variability and to hypothesize which correlated environmental or personality,variables may be active (Barlow and Hersen, 1973).

Drug abuse Although the problem of drug abuse is a very serious one, there is still very little known about its remedy. Generally, research has failed to demonstrate the value of conventional psychotherapy for drug addiction (Neuman and Tamerin, 1971). O’Donnell (1965) found in his review of eleven followup studies that the range of relapse for drug addicts varied between 8 and 90%, probably due to the varying kinds of designs used in the studies. The results available for traditional inpatient treatment programs for drug addicts indicate that 1 - 36% benefit from this kind of treatment (Knight and Prout, 1951; Retterstol and Sund, 1965; Andersson and Gunne, 1969). There are various treatment programs, however, that have utilized certain aspects of the behavioral approach, but no comprehensive behavioral program has yet been implemented and systematically evaluated (see Gstestam et al., 1976). Drug addicts are generally poorly motivated for treatment and are considered a very difficult group of patients to work with (Bejerot, 1968; Lewis

8

and Osberg, 1958). Although it has been difficult to find common personality factors among drug addicts (Campbell, 1962; Whitlock, 1970; Davis and Sine, 1971) their behavior patterns seem to be quite similar in most treatment programs, i.e. passivity and lack of interest in undergoing any kind of therapy (Maddux, 1965; Bejerot, 1968; Glatt, 1974).

A behavioral

view of drug abuse

Sources of reinforcement From a behavioral point of view, drug addiction is seen as socially acquired, learned behavior maintained by a number of antecedent cues and consequent physiological, psychological and sociological reinforcers. Cahoon and Crosby (1972) have described different sources of reinforcement for drug abuse : (1) Positive reinforcement involving secondary social support: Certain drugs seem to be increasingly accepted among high school and college students. Further, persons with drug-orientated philosophies may band together forming groups. (2) Positive reinforcement as a direct effect of the drug: Some drugs make the subject feel “good”, “euphoric”, or otherwise “happier” than before ingestion of the drug. (3) Negative reinforcement involving aversive environmental stimuli: A subhuman organism can readily be taught to terminate an electric shock by performing an operant within its capability. It is therefore not surprising to find that human subjects perform in an analogous fashion when placed in environments that generate a high proportion of aversive stimulation, (4) Negative reinforcement involving drug-related environmental consequences; logically, this category is included in the former, but it is considered separately because it may account specifically for accelerating drug consumption in some instances. (5) Negative reinforcement involving “internal” aversive stimuli not induced by the drug itself. Although this class of contingencies may be difficult to distinguish from aversive environmental (or “external”) stimuli, it is felt that a differentiation can be useful in the treatment of drug addiction. For example, many soldiers have become morphine addicts due to the use of this drug as a pain killer. Internal stimulation that might lead to consistent drug use includes anxiety, fatigue, boredom, depression and sleeplessness. (6) Negative reinforcement involving “internal” aversive stimuli induced by continued use of the drug itself. This is what is commonly called “physiological addiction”. Use of the drug creates a physiological state, including withdrawal symptoms when the drug is withheld. Acquisition and maintenance factors The problem of drug abuse and addiction can be divided conveniently into two different parts - acquisition and maintenance. The rationale behind

9

this division is that the reinforcers and discriminative stimuli maintaining addictive behaviors are not necessarily the same as those responsible for the acquisition of the problem. This has often been shown in behavior analysis of single cases (Leitenberg, 1976). The analysis of GBtestam et al. (1976) aims to demonstrate that a limited analysis and therapeutic attack on the drug taking behavior per se, although important, is insufficient. Often the behavioral repertoire of the drug addict lacks certain behaviors which makes it difficult or impossible for him to gain access to important reinforcers normally available in society. An operant analysis of behavior does not differentiate between lack of skill and lack of motivation, but merely observes that the “appropriate” behavior in a specified situation is absent. The therapist’s role is to help the patient acquire or maintain the appropriate behavior in question. This is mainly done by creating the right contingencies in the addict’s environment. During the last years, behavioral treatment programs for drug addicts have come to include three major objectives (Miller et al., 1974): (1) to decrease the reinforcing properties of the drug (both primary and secondary), (2) to teach the patient new behaviors that are incompatible with (or at least different from) drug abuse, and (3) to rearrange the patient’s social and vocational environment so that he receives maximum reinforcement for activities not involving the use of drugs. The last point has probably been the most difficult problem for therapists to work with as it requires changes of environmental factors which are often beyond the control of the therapist. Although the ultimate criterion by which to evaluate treatment programs is the drug addict’s functioning in his natural environment, the development and maintenance of skills adaptive to the hospital setting are also justified. Without a well-functioning management program there can be no therapeutic planning. The development of adaptive ward behaviors can counteract behavioral deterioration. The behaviorist’s position is that the drug addict’s behavior in most conventional treatment programs (i.e. passivity, lack of interest, aggression) are not caused by drug abuse or by a deviant personality but are rather functionally related to the environment, or, technically speaking, maintained by the contingencies of the management program on the ward. Thus, in any comprehensive treatment program for drug addicts, it is essential to arrange the contingencies for the patient and not against him. If this is done properly, it can be the first step of a rehabilitation program.

Individual behavioral

techniques

The classification of individual behavioral techniques falls into two main categories: (1) those where the primary aim is treatment of the drugtaking behavior, and (2) those where the focus of treatment is on alternative (often incompatible) behaviors.

10 Treatment of the drug-taking behavior Among the different behavior principles for reducing or eliminating maladaptive behavior, both punishment (classical aversive conditioning) and extinction have been used in the treatment of drug addiction in individual therapy (see Ggtestam et al., 1976). Aversion therapy The three types of aversion therapy mostly used with alcoholics and sexual deviates have also been applied to drug addicts: Faradic aversion, chemical aversion, and verbal aversion. Faradic aversion. The use of electric shocks in this treatment was first presented by Wolpe (1965) who instructed his patient to apply severe shocks to himself from a portable induction coil. The best description of the technique is provided by O’Brien et al. (1972). After a careful behavior analysis the conditioned stimuli that elicit the drug-taking behavior were divided into three groups: “(1) Intrinsic stimuli associated with craving; (2) Extrinsic stimuli associated with preparing to inject; and (3) Stimuli associated with the effects of a heroin injection”. Then drug related scenes using the patient’s own jargon were prepared. Included in these scenes were stimuli from each of the three groups above. Chemical aversion. In this category there are two different techniques, one which produces nausea and perhaps vomiting, and the other which leads to apnea. Apomorphine has been used by Raymond (1964) in the treatment of an opiate addict. The patient is given a subcutaneous injection of apomorphine. Five to ten minutes later the patient is given a syringe with a small amount of his drug of addiction. The patient is instructed to give himself the drug intravenously as he usually does. Included in this treatment was also a choice situation, where the patient could choose between a syringe with the drug and coffee, soft drinks, etc. If he chose the socially appropriate items, he was reinforced socially by the therapist. An aversive technique which has been used in the treatment of alcoholics and drug addicts is the application of a drug that causes temporary respiratory paralysis, which is very traumatic. This aversive technique is difficult to defend from an ethical point of view. Rachman and Teasdale (1969) in their thorough review of aversion therapy conclude, “As there is no longer any reason for supposing that the scoline-conditioning method is particularly effective in treating alcoholism, we feel that this is the right moment to terminate investigations of this type”. We fully agree with Rachman and Teasdale. Verbal aversion. The third category of aversive stimuli used in the treatment of drug addicts is based on the patient’s imagery. Kolvin (1967) called the technique “aversive imagery”. Anant (1968) called it “verbal aversion technique”, while Cautela (1967) named it “covert sensitization”, a term which seems to have been adopted by most behavior therapists.

11 Steinfeld (1970) used the technique as presented by Cautela (1967) with a patient who was instructed to imagine that he was performing the drug-taking behavior step by step. At every step in this sequence the aversive image (being sick and vomiting) was presented. This gradually worsened and at the moment when he was going to inject the drug he imagined that he was vomiting all over himself.

Extinction Rubenstein (1931) used a classical extinction paradigm in treating two patients with tuberculosis who were addicted to morphine. Compared to the current gradual detoxification routinely used for opiate addicts in hospitals, the comprehensive procedure described in Rubenstein’s paper seems rather superfluous. Cautela’s (1971) description of covert extinction has been used in the treatment of four female amphetamine addicts (Gotestam and Melin, 1974). First, the therapist interviewed the patient to obtain detailed information about the situations in which she injected amphetamine. During treatment “one of these situations was presented to the patient, making sure that she could follow and vividly imagine the situation. Finally, the patient was told to imagine that she got no flash, and that she felt no effect whatsoever”. This treatment is an example of operant extinction since the reinforcing stimulus (flash) does not follow the response (injecting the drug) as it ordinarily does. Three of the addicts had not taken amphetamine during the nine-month follow-up period.

Treatment

of alternative

behaviors

Some authors in this field feel that the acquisition or strengthening of alternative (mostly incompatible) behaviors should be the primary aim of treatment. Others have treated the supposed underlying anxiety, which they think leads to the drug-taking behavior. Finally, some have presented broadspectrum approaches to the treatment of drug addiction.

Desensitization

and relaxation

The use of systematic desensitization and relaxation training has been presented by several authors (cf. Gotestam et al., 1976), mainly for the anxiety related to the drug addiction.

Assertiveness

training

Because most drug addicts are in several respects non-assertive, assertive training is a useful technique, together with training of coping behaviors in stressful or drug-related situations (cf. ibid).

Covert conditioning The techniques subsumed under the label covert conditioning (covert sensitization, covert extinction, covert positive reinforcement, covert negative reinforcement, covert modelling) have mostly been devised and devel-

12

oped by patient’s to which category 1966).

Cautela (1973). In these techniques the treatment is based on the imagination. He is to imagine that he performs a certain behavior there is some kind of specific consequence. Other techniques in this are thought-stopping (Wolpe, 1969) and coverant control (Homme,

Contingency

contracting

The use of contracts specifying the relationship between the target behavior and positive or negative consequences for performing undesirable behavior has been used in the treatment of school problems, delinquency and weight reduction. The first to describe its use in the treatment of drug addicts was Boudin (1972), who successfully treated a female student abusing amphetamine.

Broad-spectrum

approaches

Although many of the articles reporting behavioral treatment of drug addicts applied more than one technique, there are few authors who have specified the need for a combination of techniques. Cheek and her co-workers (see Gotestam et al., 1976) have used relaxation, desensitization, idealized self-image, behavior rehearsal, modifying undesirable behaviors, and selfassertion. O’Brien and Raynes (1974) suggested that “a comprehensive treatment of drug abuse would involve the elimination of undesirable antecedent cues, the manipulation of consequences and the development of suitable alternative drug free behavior or behaviors. Ideally the therapeutic program should include attempts to foster alternative, acceptable social behavior patterns. It is important that the drug addict be provided with treatment for other co-existing problems as well as counseling, reassurance and possibiliThey used relaxation, desensitization, ties for vocational rehabilitation”. assertive training and aversion therapy. In a recent report by Copemann (1976) where aversion therapy and behavioral group therapy was used, a high proportion of the patients remained drug free at the two-year follow-up, 80% (24 patients) of all patients completing treatment (corresponding to 48% out of the patients who began treatment).

Ward programs In a series of studies at Uller&ker Hospital in Uppsala, a ward for drug abusers was developed via a contingency management system (Melin and Gotestam, 1973; Melin et al., 1976) to a token economy (Eriksson et al., 1975).

Conventional

ward structure

The ward programs were run on two different wards. Programs 1 - 3 were run on one ward, and Program 4 on another. At the start of the study, these two wards served identical purposes, one for females and one for

13

males. When Program 3 started, the ward was changed to take both males and females in the methadone maintenance treatment program. When Program 4 started, all inpatients with drug dependence were treated in this ward. The first ward at the time prior to Program 1 had two general functions: (1) to detoxify female addicts voluntarily or involuntarily admitted to the hospital, and (2) to run a voluntary drug-free treatment of detoxified addicts. Many patients did not want to take part in the drug-free treatment program, and were therefore discharged after detoxification. The ward had 12 beds, one room with 3 beds, two with 2 beds and five with one bed. One single room was reserved for acute cases. There was no systematic distribution of beds to patients other than availability. The ward also held a high staff to patient ratio (1: 2). The more or less explicit rule system was described in the following way: Medical criteria. The patients had two kinds of medical status: intoxicated or detoxified. This was established by a daily chemical urine analysis. If traces of illegal drugs were found the patient was considered intoxicated and if not, was considered detoxified. The decision had very profound social consequences, which, in the case of a positive analysis, were however, delayed until the following day. Before urinating the patients were bodychecked. As this control was not entirely fool-proof, some traceable inert substance was sometimes given to patients. Intoxicated patients were not allowed any privileges like leave, outdoor walks with staff, or visitors, but once no drugs were found in the urine they were immediately entitled to outdoor walks with personnel, and after a week also to the other privileges. The prescription of sedatives and psychotropic as well as hypnotic drugs was restricted; but during the month before the program started the patients received an average of 7 pills a day (5 during the day and 2 sleeping pills). If a patient with privileges took amphetamine she went back to detoxification and lost her privileges. It was, however, very difficult to keep these regulations. If the patient confessed to the staff that she had taken drugs, it was difficult to punish her honesty. Thus many patients kept some of their privileges even if they had been intoxicated.

Social criteria. Every detoxified patient had to take part in the daily activities offered to her: occupational therapy, physical therapy, courses, excursions and routine work on the ward. There was also a rule to get up and make the bed before 8.00 a.m. Important to note is that there were no sanctions, positive or negative, linked to the patients’ activities. Every morning their medical status and whereabouts were discussed at a ward conference and sanctions were decided, but not according to any specific rules. Program 1: Introduction

of activities

and rules

Program 1 started with the purpose of improving the management the ward, introducing a rule system and increasing the activities of the patients (see Melin and Gfltestam, 1973).

of

14

Sixteen female patients took part in Programs 1 and 2, all of them intravenous amphetamine addicts. Some of the patients also had other problems of a neurotic character (psychotic patients were excluded). The criterion for inclusion in the study was that the patient had to spend at least one day in the rehabilitation phase.

Preliminaries. There was a 14-day training program for personnel, where basic learning principles were explained. Baseline data were collected prior to the program. Instructions and discussions about the program also preceded the program. It was stressed that the program should be looked upon as a training process. Procedure. The new program was designed to have three phases: detoxification, treatment, and rehabilitation. These three phases were carried out in different locations. A room with 3 beds was used for detoxification. Two rooms with 2 beds each were used for the treatment phase, and single rooms for the rehabilitation phase. The patients could decorate their private rooms but the detoxification room was to be considered a sickroom and looked very bare. The two treatment rooms were in-between. (1) Detoxification phase. On admission, every patient entered this phase and remained there as long as drugs were found in her urine. She was considered ill and was not allowed to take part in any ward activities. When drug-free she was invited to a treatment conference where she was informed about the program. (2) Treatment phase. In this phase the patient was allowed to take sleeping pills only in exceptional cases. Low frequency behaviors were to some extent tied to high frequency behaviors. High and low frequency behaviors were identified from time-sampled observations made of patient activities and from patient ratings of activities. (3) Rehabilitation phase. When the patient seemed to get on well in the treatment phase for about a week she was moved to the rehabilitation phase. Otherwise she had to stay in the treatment phase. The rehabilitation phase contained more high frequency behaviors (reinforcers) than the treatment phase. In this phase we also worked with the patient to find a way back into society. If the patient did not get on well in this phase, she was moved back to the treatment phase, and if she relapsed to taking drugs she was moved back to the detoxification phase. Results. The results will be described grams 1 and 2 taken together. Program 2: Flexibility

between

activities

The greatest disadvantage of tions for not getting along well in lower phase always led to conflicts Because of this disadvantage out, i.e. a point system. That was

in the following

section

for Pro-

and reinforcers

Program 1 was the distribution of sancthe program. Moving a patient back to a between patients and personnel. a quantification of activities was worked done by putting weights (points) on low

15

frequency behaviors according to the principle: the lower the frequency a specific behavior the higher the weight (Melin and Gotestam, 1973).

of

Procedure. The new, modified program was thus quite similar to a token economy program. There were, however, some differences. The scores were kept by the patient’s contact man but the scoring was made with the patients. The scores could not be used for access to specific privileges. Instead the patient had to meet certain requirements to get the privileges in the phase. With this modification of the program two advantages were gained: (1) a quantification of the rules on the ward, and (2) an increased flexibility for the patient. She could now choose activities more freely and even take a day off in the rehabilitation phase when she had collected enough points for the week. Results. Getting up and dressed before 8 a.m., which was earlier considered a problem, increased first in Program 1, and even more in Program 2. The increase was significant at the 1%” level (Kruskal-Wallis one-way analysis of variance). Doses of prescribed psychotropic drugs decreased significantly from a one-month period preceding the program to the first 7 weeks of Program 1 (t-test, p < O.O5).The weekly number of home calls the doctor received from the ward was related to psychotropic drug prescriptions. This personnel behavior, dependent upon patient behavior, decreased from 6 times/week during the base-rate period to 0.4 times/week during the first 7 weeks of Program 1. Program 3: Stepwise access to reinforcers The quantification in Program 2 made it easier to record the performance of target behaviors although access to the reinforcers was still all-ornone, and there was also no differentiation between the reinforcers. This disadvantage was partly eliminated in a similar program with opiate addicts in a methadone maintenance program (Melin et al., 1976). The patients were admitted to the ward from all of Sweden for one of the following three reasons: induction onto methadone after detoxification on another unit; problems concerning the methadone dose level; or detoxification from methadone and removal from the methadone maintenance treatment program. Preliminaries. After two weeks’ stay on the ward, the patients had access to privileges like outdoor walks with personnel and leave. Re-admitted patients, earlier induced onto methadone, received these privileges from the first day. If a patient took illegal drugs (detected by daily urine analysis) he lost his privileges for one week. Procedure. Program 3 was similar to Program 2. The patients gradually got access to privileges under similar point principles. The study consisted of the following phases: Al: Baseline period. Bl : The first week in the contingency management program, where activi-

16

reversal”, where the program ties were tied to privileges. A2: “Accidental was not running due to the absence of the psychiatrist in charge of the program. B2: The contingency management program. A3: A reversal was included for the activity “making bed and room”. No points were given for making bed and room during this period, and the criterion level was changed accordingly. B3: Points were again given for making bed and room.

Results. After the start of the program, the total activity (average number of points per person per week) increased considerably during the first week (25.2 points in Bl) compared to the baseline activity level (13.9 points in Al). During the “accidental reversal” the activity decreased, but not to the baseline level (22.7 points in A2). When the program was again running, a high activity level was regained (33.4 points in B2). This meant that the criterion level of 25 points was surpassed during the program periods but not during baseline periods. The baseline periods (A) were compared to program periods (B) in the following manner. The number of points was calculated for each patient during 5 days before and 5 days after a shift from baseline period to program period or vice versa. These average numbers of points increased from 3.1 in A phases to 5.1 in B phases, which is significant at the 1% level (t-test). Program 4: Increased flexibility tained activity

between

activities and reinforcers plus sus-

In Program 3 there were two disadvantages in the contingencies. First, it did not matter if the patients collected more than 25 points per week (the maximum was 46), which was the criterion for privileges. Thus high activity levels in the patients were not reinforced, but rather extinguished. The results also indicated an asymptotic adjustment to the criterion level. Secondly, there was a delay of negative consequences for one week, i.e. a patient could choose not to perform any of the target behaviors during one week and still retain all the privileges that week (provided he had reached the criterion the preceding week).

Procedure. Program 4, which was a token economy, was run on another ward than the three earlier programs. This ward consisted of two units, one for detoxification (11 beds) and one for treatment (11 beds). Before a patient could enter the treatment unit he had to be detoxified. The detoxification unit was similar to a somatic hospital with no recreational activities. All patients participated in the treatment program voluntarily and could leave the ward whenever they wished. The patients could wear their own clothes and have much more freedom. The treatment unit consisted of three twobed rooms, five single rooms, a dayroom, a music room, a dining room and a kitchen. Activities. The activities that the patients could perform into two categories: 14 common activities (which all patients

were divided could perform),

17

and 21 bookable activities of which only one at a time could be performed (Eriksson et al., 1975).

Reinforcers. Leaving the ward when activities were finished (4 p.m.) was free, providing the patient had collected 15 points the preceding day. Points collected above 15 points per day, were considered as surplus points. These could be used to get access to 10 other reinforcers. An A- BP A- BP C design was applied. The first phase (Al) was a baseline period during which a “therapeutic community system” was running. Then the token economy program started (Bl). A reversal period (A2) followed, and then another token economy period (B2). The study was finished by a non-contingent phase (C). This meant that the patient started each morning with the mean number of points per patient and day for the B2 phase, and further points could not be collected through the activities. Results. If Bl and B2, i.e. when the token economy was in effect on the ward, are considered as treatment phases, and Al, A2 and C, i.e. baseline, reversal and non-contingent reinforcement, are considered as non-treatment phases two groups of patients emerge: (1) 12 patients who participated first in Al or A2 and then in Bl or B2, respectively; and (2) 13 patients who were first in treatment phases and then in non-treatment phases. For these patients the mean number of points collected per day was calculated for the last 5 days of their first phase and the first 5 days of their second phase. For the first group of patients, the mean number of points per day increased from 8.7 to 16.3, and for the second group there was a decrease from 19.5 to 9.6. Both changes are significant (t-test for correlated samples) at the 1% and 1% level, respectively. This way of analyzing the data shows a significantly higher activity level when the token economy was running compared to when it was not. Comparison

between

the ward programs

In Table 1, the four ward programs and their assessment are compared. In Table 2 an evaluative comparison between the four ward programs is performed. It is apparent that the shortcomings in the first programs have gradually been more or less solved in the later programs, and that the token economy as a form of ward management did not have any major disadvantages. The token economy could, however, be improved through the introduction of more individual programs within the general frame of the token economy. An outline of such a comprehensive program for the treatment of drug addicts follows.

Outline of a behavioral

program for drug abuse

Solomon and Marshall (1973), in their theoretical article, have discussed some implications for treatment of drug abuse. In the general outline of a

1

description

*p = points.

Assessment: No. of variables Reliability

No. of activities No. of reinforcers Treatment time (mean) Program period Design

Treatment program: Rules and phases

Comparative

TABLE

Program

4

4 97% (for one)

24 days (12-52) 8 months A-B-C

11 4

10 97,100,62% (for three)

12 97, 83, 100, 83, 93% (for five at the beginning of the program); 100% (for all five at end of program)

34 11 17 days (2-202) 8 months A-B-A-B-C

3

10 5 27 days (3-107) 5 months A-B-C-B

Program

7 .4

2

Two steps: before and after, 70 p. To keep the privileges the patient had to collect 15 p/day. Surplus points could be used to buy backup reinforcers.

Program Five steps: 0, 25, 50, 75 and 100 p. The patient had to collect 100 p to get all privileges and 25 p/ week to maintain them.

1

Three phases: (1) detoxification, (2) treatment, (3) rehabilitation. To proceed from l-2 = 5 p*, from 2-3 = 25 p. To remain in phase 3 = 25 p/week.

Program

of the ward programs

2

1. No flexibility between activities and reinforcers 2. Difficulty to distri. bute negative consequences

1

Shortcomings

Program

the four programs

1. Increased patient activity 2. Explicit rule system

between

Advantages

Comparison

TABLE

1. No differentiation between reinforcers

1. No use of surplus points 2. Negative consequences delayed one week

2. Increased flexibility : higher number of optional activities 3. Surplus points give access to different reinforcers 4. Negative consequences delayed only one day

4

2. Increased flexibility: stepwise access to reinforcers

Program

2. Increased flexibility between activities and reinforcers

3 1. Same

Program 1. Same

2

1. Same

Program

20

behavioral treatment program, some of their suggestions will be referred and general suggestions for individual interventions will be presented.

to

A token economy frame An operant program as a token economy is a good frame for individual treatment programs. The detoxification of the patients may take place in a token economy, or in a conventional ward milieu. Preferably the detoxification should take place on a unit separated from the treatment unit. The token economy could be designed as Program 4, presented above (Eriksson et al., 1975), but need not follow an experimental procedure. Negative sanctions should not be too much delayed. Individual behavior analysis Behavioral analysis of individual problems (Kanfor and Saslow, 1969; Kanfer and Grimm, 1977) is very important as a foundation of an individual treatment program. The analysis should reveal which maladaptive behaviors should be decelerated, and which adaptive behaviors should be accelerated. Also, the patient’s resources (for example, education, a hobby, or some other interest) should be considered. Decreasing the drug-taking behavior One possible way to decrease the drug-taking behavior is by use of aversive procedures. In such cases, however, these procedures must be used in combination with other procedures to increase alternative behaviors. Another procedure is extinction, where covert extinction (Gotestam and Melin, 1974) seems to be most suitable for practical reasons. The purpose of these procedures is to reduce the probability of the drug-taking behavior in the presence of familiar eliciting cues. Increasing alternative behaviors The purpose of increasing alternative behaviors is to encourage and reinforce activities interesting to the patient, to exclude his engaging in drugtaking behavior. This may include education, job training, and introduction of leizure activities. These kinds of activities could be reinforced by social or material reinforcers. It is always very difficult to find alternatives which really possess reinforcing properties for a drug addict who has experienced the high reinforcing power of dependence-producing drugs. Training to cope with stress etc. Some patients may have special neurotic problems which require treatment. The conditioned abstinence also makes him feel uncomfortable (anxious) when perceiving familiar stimuli that orginarily elicit drug-taking behavior. He must be trained to react not to these cues as in the earlier fashion, but with new adaptive responses. Assertive training may also enhance his self-regard and in turn decrease the probability of drug-taking behavior.

21

Changing the social situation The social situation must be restructured to make it possible for the drug addict to live a life without using dependence-producing drugs. This may include housing, work, family, friends, or anything necessary to compose a good constructive social environment.

Contingency

contracting

A contingency contract, where contingencies for maladaptive behaviors are specified, should be designed for each patient. During the initial phase of treatment (after detoxification) which could, but not necessarily needs to, take place in a hospital, such a contract should be in effect on a one-week basis. Later on longer periods of contracting are suggested (Ggtestam and Bates, 1979).

Regular patient

conferences

At the beginning of treatment, weekly conferences should be held with the patient, the staff, and other personnel, to plan activities and training sessions and so on for the next few days. At every patient conference the progress since the last conference is checked, and appropriate modifications of the plans are made. Later on, these conferences may be more spread out in time. It is important, however, that these conferences are held often enough to give the patient a real chance to perform some planned activity, and also to be reinforced for it. Discussion Many questions remain to be answered before it is possible to decide whether behavior therapy techniques are the treatment of choice in the field of drug abuse, In spite of the often very subtle theoretical argumentation of scientifically orientated therapists, there is an almost total lack of satisfactory research in this field. Although we know that drug addicts’ behavior may be controlled in inpatient programs, there is no conclusive evidence that behavioral methods have retained their value at follow-up. However, in recent years there has been a trend towards more controlled studies and in a few years it will be possible to draw some modest conclusions about the therapeutic effects of behavioral methods. What the studies in this field have shown are that behaviors of addicts, social or addictive, can be controlled by proper manipulation of reinforcers and/or discriminative stimuli. None of these studies has yet been conducted with representative samples of drug addicts, so that the general value of these methods remains to be demonstrated. Early classical conditioning studies concentrated mainly on the acquisition of aversive discriminative stimuli for the “fix”. These procedures required that stimuli leading to the taking of the drug should be isolated by the therapist. Both in theory and in practice this is a very difficult task, since these stimuli are often complex or else they are links in long stimulus-

22

response chains, i.e. each stimulus will have acquired a secondary reinforcing value for the behavior it follows and each reaction will act as an additional stimulus for the next reaction. Very early points in the behavior stream that ultimately leads to taking the drug might be the addict’s fantasies about the drug effects. It may be difficult in these stimulus-response chains to determine whether a phenomenon is a component of behavior or an eliciting stimulus. Since the sole function of the aversive techniques has been to change the valences of the conditioned stimuli that elicit drug taking it is no wonder that the results have been far from impressive. In these studies the patient’s alternative to drug-taking behavior has been left to chance. On the other hand, a treatment program aimed only at building up behaviors alternative to or incompatible with the drug-taking behavior, might also be too limited to meet with success, as the conditioned stimuli involved and the strong reinforcing effects of the drug probably exert a strong control over the addict’s behavior. What has been demonstrated so far is that it is possible to increase useful behaviors on the ward and at the same time to decrease drug-taking behaviors as a result of changed contingencies. However, when the patients have left the ward their newly acquired behaviors have tended to decrease and their problem behaviors have tended to increase (Atthowe, 1973). This common experience should induce every comprehensive treatment program to plan for generalization from the treatment situation to the patient’s natural setting. Behavior therapy has much to offer in the analysis and handling of this problem (cf. Kazdin and Bootzin, 1972), but no planned extension from individual treatment programs or ward programs to post-treatment settings has yet been conducted with drug addicts. An interesting clinical observation with drug addicts is that they seem to consider most unpleasant bodily sensations as abstinence phenomena. Common cold, low mood, feelings of helplessness are interpreted as abstinence symptoms and thus solved by drug taking. In our experience it is important to teach the addict to judge bodily sensations adequately and to teach him diversified ways of coping with these “normal” problems. The gradual shift from classical aversive conditioning treatment to operant or situation-orientated treatment programs is beginning to close the gap between the institutional treatment of addicts and their situation when back in society. Treatment programs that concentrate on ward structure and run on operant principles have shown that it is possible to motivate addicts to engage in activities other than and even incompatible with, drug-taking behavior when they are still in the treatment program. Since the weak point of all drug treatment programs is the relevance of the institutional treatment in respect of adjustment to society, careful studies must be conducted on the effects of different contingencies in the different social contexts that an exaddict will meet. Besides changing the patient’s post-treatment situation he must learn skills which will make him attractive to new reference groups. As drug-taking behavior may have a coping function for many negative reinforcers such as sexual desire, pain, and loneliness, more adequate and diversified coping skills

23

must be taught. These new coping behaviors should be analyzed regarding the possibility of their being positively reinforced in the patient’s natural environment, Since reinforcing stimuli are highly idiosyncratic an individual program must be established for each patient. Individualized operant programs have been successfully applied in other similar areas such as alcoholism (Hunt and Azrin, 1973). The validity of a behavioral view of drug addiction is an empirical question. On the basis of existing data it is not possible to recommend a behavioral approach wholeheartedly. However, the rapid growth of empirical knowledge in this field allows a careful optimism for a substantial contribution to the future solution of this very serious problem.

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