Module 5:
Brief Behavioral Therapy Based on OperantLearning
TIP 34 Reference
Chapter5:BriefBehavioral TherapyBases on Operant Learning (pp.55-61)
Training Emphasis
1.Key Concepts of Brief Behavioral Therapy Based on Operant Learning
2. Models Used for Brief Behavioral Therapy Based on Operant Learning
3. Research on Brief Behavioral Therapy Based on Operant Learning
4. Types of Settings and Clients Appropriate for Brief Behavioral
Therapy Based on Operant Learning
5. Applications of Brief Behavioral Therapy Based on Operant Learning in
Substance Abuse Treatment
6. Duration of Brief Behavioral Therapy Based on Operant Learning
7. Evaluation of Effectiveness of Brief Behavioral Therapy Based on
Operant Learning
8. Strategies Used for Brief Behavioral Therapy Based on Operant
Learning
9. Participant Strategy Integration
Learning Objectives
1.Participantswill beabletoidentifythree keyconceptsaboutbrief behavioraltherapy basedonoperantlearning.
2.Participantswillbeabletoidentifythreemodelsused forbrief behavioral therapy basedonoperantlearning.
3.Participantswillbeabletoidentifythreeresearchfindingsaboutbriefbehavioraltherapybasedonoperantlearning.
4.Participantswillbeabletoidentifythreesettingsorclientsappropriate forusingbriefbehavioraltherapybasedonoperantlearning.
5.Participantswillbeabletoidentifythreeapplicationsofbrief behavioral therapybasedonoperantlearningwithsubstance abusers.
6.Participantswillidentifyonenewbriefbehavioraltherapybasedonoperantlearningstrategytointegrateintotheirpractice.
7.Participantswill identifyatleastonequalityassuranceandimprovementprocedureforthenewbriefbehavioraltherapybasedonoperantlearningstrategy.
Agenda
1.Welcome(2Minutes)
2.BriefBehavioralTherapyBasedonOperant LearningSummaryGrid OverviewandDiscussion(20Minutes)
3.StrategyIdentification Exercise(10Minutes)
4.StrategyIntegration Mind-MapExercise(10Minutes)
5.AssignmentsandClosing(3Minutes)
Training Equipment and Supplies
1.Whiteboardanderasablemarkers–OR–newsprintpad,markers,andeasel
2.LCDprojector–OR–overhead transparencyprojector
3.PowerPointslideCD–OR–overheadtransparencies
4.Moveableseating
5.Nametags(optional,reusableordisposable)
6.Attendancerecord
7.Pens andcoloredpencilsorcrayons
8.Continuingeducation certificates(optional)
Definition of Terms
OperantLearning:Operant learning refers to the process by which behaviors that are reinforced increase in frequency. Behaviors that result in positive outcomes or allow the client to avoid negative consequences are likely to increase in frequency. Substance use in the presenceof classically conditioned cues is instrumental in reducing or eliminating the arousal associated with a state of craving, thus serving to reinforce the substance abuse behavior. That is, the behavior serves as a basic rewarding function for the individual.
FunctionalAnalysis:A process used in behavioral and cognitive– behavioral therapy that probes the situations surrounding the client’s substance abuse. A functional analysis examines the relationships among stimuli that trigger use and the consequences that follow. This can provide important clues regarding the meaning of the substance use behavior to the client, as well as possible motivators and barriers to change. Inthese forms of therapy, this is a first stepinprovidingtheclientwithtools tomanageoravoidsituationsthat triggersubstanceuse.Functionalanalysisyieldsaroadmapofaclient’sinterpersonal,intrapersonal,andenvironmentalcatalystsandreactionstosubstance use,therebyidentifyinglikelyprecursorstosubstance use.
ContingencyManagement: Acontingencymanagementapproachattemptstochange thoseenvironmentalcontingenciesthatmayinfluencesubstance abuse behavior.Thegoalistoincreasebehaviorsthatareincompatiblewithuse.Inparticular, contingenciesthat arefoundthroughafunctionalanalysistopromptaswellasreinforcesubstanceuseareweakenedbyassociatingevidenceofsubstanceabuse(e.g.,adrug-positiveurinescreen)withsomeformofnegative consequenceorpunishment.Contingenciesthat promptandreinforcebehaviorsthat areincompatiblewithsubstanceabuseandthatpromote abstinencearestrengthenedbyassociatingthemwithpositivereinforcers.
Participant Materials
(OneforEachParticipant)
1.Module6Handouts
a.Module6Packet Cover
b. Brief Behavioral Therapy Based on OperantLearning SummaryGrid
c.StrategyIdentificationExercise
d.StrategyIntegration Mind-MapExercise
2.Homework:HandoutsfornextTIP 34 TrainingModule
Module 5 - Section 1
Welcome & Introduction
Time: 2 Minutes
Trainer Notes
Thissectioncanbedidacticorinvolvelowgroupinteraction.
Trainerandparticipantintroductionsarenotnecessary as theseweredoneinModule1.
Trainer Script
Welcome & Topic Introduction
WelcometotheTIP 34trainingonBriefInterventionsandBriefTherapies. Ourtopicforthistrainingis“BriefBehavioralTherapyBasedonOperantLearning.”Thegoalofallbrieftherapiesistoprovideclients withtoolstochangethoughts,attitudes,and/orbehaviors.WewillexploreavarietyofaspectsaboutbriefinterventionsthatarehighlightedontheBriefBehavioralTherapyBased onOperantLearningSummary Gridinyourhandoutpacket.Wewillalsouse the Strategy IdentificationExerciseandtheStrategy Integration Mind-Maptoidentifyanewstrategythatyouwillintegrateintoyourpersonalpractice.
Module 5 - Section 2
TimeClock
TrainerNotes
Brief Behavioral Therapy Based on Operant
Learning Summary Grid
Time: 20 Minutes
Trainer Notes
Thissectionisacombination ofdidacticpresentationandlargegroup discussion.Itcaninvolvelowtohighgroupinteraction.
Thetrainer should notread each itemfromtheSummary Grid. Summarizingeach sectionofthegrid,aswellasaddingadditional information availableinthetrainerscriptorthroughpersonalclinical experience,willmakethetrainingmoreinteresting.
Integratinggroupdiscussionswitheachsectionwillenhancethe effectivenessofthetraining.Groupdiscussionsallowparticipantstolearnfromoneanotheraswellasfromthetrainer.
Thetrainer alwaysfacilitatesthegroupdiscussionandinteraction.The trainer’sroleistoprovideexpertiseandguidance,andnottoprescribetheuseofanyonemodelforbrieftherapy.Thetrainer maintainsfocusofdiscussionsonthetopic,andisalsotheleaderand timekeeper forthegroup.
Thefocustopicofthediscussionsisthefeasibilityofusingtheseapproacheswithintheguidelinesandservicesoftheagency.
Thetrainer caninitiatediscussionwithopen questions:
■Does anyoneinthegrouphaveexpertiseinusingbriefbehavioral therapybased on operant learning approaches?
■Whattypes ofbriefbehavioraltherapy based on operant learningstrategiesarewithinthe establishedguidelinesforouragency?
■Whattypes ofbriefbehavioraltherapy based on operant learningstrategiesarecurrentlyusedinouragency?
■Whatothertypesofbriefbehavioraltherapy based on operant learningcouldbeusedinour agency?
■Whatresourcesforbriefbehavioraltherapy based on operant learningexistoutsideofour agency?
TIP 34 Reference
Chapter5:BriefBehavioralTherapyBased on Operant Learning(pp.55-61)
TIP 34 Book
Participant Workbook
Participant Workbook
■BriefBehavioralTherapyBasedOnOperant LearningSummaryGrid
Trainer Script
Key Concepts
Thisbehavioraltherapyis basedontheprinciples oftheSkinnerian operantlearningmodel. The theory asserts that humanbehavioris largelylearned,ratherthandeterminedbygeneticfactors,andthatchangesinbehaviorcome aboutthroughlearningnewbehaviors.
Operantlearningreferstothosebehaviorsthat areincreasedin frequencybyreinforcement(stimulus andresponse).Behaviorsthatresultinrewardingorpositiveoutcomes,andbehaviorsthat avoidorescapenegativeconsequences,arepositivelyreinforcedandlikelytoincreaseinfrequency.
Inthepresenceofclassicallyconditionedcuesthatcausecraving, substanceuseiseffectiveinreducingoreliminatingcraving,thusservingtoreinforcesubstanceusebehaviors.Thebehaviorofusingsubstances servesasabasicrewardfunctionfortheindividual.Thisrepresentsthesecondformoflearning,operantconditioning.
Totheextent thatsubstanceabusersexperiencetheeffectstheyseek, thegreaterthelikelihoodtheywill use substances undersimilarcircumstancesinthefuture.
Presumably,people continue toabusesubstancesdespitenegative consequences(e.g.,legal,marital,orhealthproblems) because these consequencesarequiteremoved intimefromthepointofuse.Inaddition, thepsychotropiceffectsofthesubstancecauseimmediateandpositivereinforcementofthebehavior,andtypically overrideconsiderationofpossiblenegative consequences.
Thegoalofthisbehavioraltherapycanbeachievedbyassessingthe operantreinforcementpatternsthatmaintainthesubstance abuse.
Thecornerstoneofadequatetreatmentisathorough behavioralassessment.Eachclientisunique andmustbeassessedasan individualinaparticularcontext.
Changes inbehaviorcomeaboutthroughlearningnewbehaviors.Thesamelearningprocessesthat createproblem behaviorscanbeused tochangethem.
Substanceabusebehaviorcanbechangedbyteachingtheclientmore adaptive,alternativebehaviorsaimed atachievingthesamerewards. Actuallyengaginginnewbehaviorinthecontextinwhichitistobeperformedisacriticalpartofbehaviorchange.
Theaimoftherapyistohelptheclientaddressspecific,identifiable problemssothattheclientisabletoapplythebasic techniquesandskillstotherealworld,withouttheassistanceofthetherapist.
Brief Behavioral Therapy Based on
Operant Learning Models
Thereareavarietyoftherapeuticmodels usedintheoperantlearning approachofbehavioraltherapy.
1.FunctionalAnalysis
2. Contingency Management
3. Behavior Contracting
4.CommunityReinforcementApproach(CRA)
5.BehavioralSelf-ControlTraining
Functional Analysis
Only bycontinuallyassessingtheclient’sprogressandproblemscanthetherapistaccomplishthegoals ofbrieftherapyinthelimitedtimeframe.
FunctionalAnalysisisoftenused inbriefbehavioraltherapytoassessstimulithat triggeruse,theconsequencesthat follow,themeaning of thebehaviortotheclient,aswellaspossiblemotivatorsandbarriers tochange.Itprobesthesituationssurrounding theclient’ssubstance abuse.
Inbehavioraltherapy,functionalanalysisisthefirst stepinprovidingtheclientwithtoolstomanageoravoidsituationsthat triggersubstanceuse.
Functionalanalysisyieldsaroadmapofaclient’sinterpersonal, intrapersonal,andenvironmentalprecursors,catalystsandreactionstosubstance use.Functionalanalysisisalsoanimportantmodelin Cognitive–BehavioralTherapy.
Contingency Management
Thegoal of the ContingencyManagementmodelistochange environmental factors(contingencies)that caninfluence substanceabuse behavior.
Ituses strategies that focusondecreasingorstoppingsubstanceuseandincreasingbehaviorsthat areincompatiblewithuse,suchasurinesamples, vouchersystems,take-home incentives,andjobtraining.
Contingenciesthatpromptaswellasreinforcesubstanceabuseare identifiedthroughafunctionalanalysis.
Targeted contingenciesareweakenedbyassociatingevidenceof substance use (e.g.,adrug-positiveurinescreen)withsomeformofnegative consequenceorpunishment.
Contingenciesthatpromptandreinforcebehaviorsincompatiblewith substanceabuseandthatpromote abstinencearestrengthenedby associatingthem withpositivereinforcers.
Contingencymanagementproceduresareoftenembeddedina comprehensivetreatmentprogram,andoftencombinedwithmore comprehensiveapproaches,such ascommunityreinforcementand behavioralself-controltraining.
Behavior Contracting
Theactofcomposingandsigningacontractisasmallbutpotentially important ritualsignifyingtheclient’scommitmenttotheproposedchange.ThisiswhatmakesBehaviorContracting aneffectivemodel.
Contractstargetinggoals supportive ofrecoveryaregenerallymorelikelytobeachievedandleadtobetteroutcomesthanthosemoredirectlyrelatedtosubstance use.
Theeffectivenessofsuch contractsalsoappearstobelinkedtotheseverityoftheconsequencesthat mightresult fromabrokencontract.
Behaviorcontractsareoftenfoundas elementsinanumberofmore comprehensiveapproachessuchastheCommunityReinforcementApproach(CRA)andBehavioralSelf-Control Training.
Community Reinforcement Approach (CRA)
TheCommunityReinforcement Approach (CRA)was originally developed asatreatmentforalcoholabusedisorders.Itisabroadspectrumapproachbasedontheprinciples ofoperantlearning.
ThegoalofCRAistoincreasethelikelihoodofcontinuedabstinencefromalcoholordrugsbyreorganizingtheclient’senvironment.
Environmentalreorganizationisachieved byincreasingtheavailabilityandfrequencyofreinforcementsthatareincompatiblewithsubstance abuse.CRAhelps clientslearnaboutandsampleanumber of substance-freepursuitsandsocial activities.
These reinforcementsarederivedfromalternativevocational,family, social, andrecreationalactivities.
Thesealternativeinterpersonalandsocialactivitiesaremade available whentheclientissoberordrug-free,butmade unavailable iftheperson drinksor uses drugs.
Alternativereinforcementscanbetailoredtothespecific circumstancesofaclient.
Behavioral Self-Control Training
Behavioral Self-Control Trainingapproachfocusesonthesubstance abuserandhis/herattemptstoreduceorstopsubstanceabuseeither onhis/herownorwiththeaidofatherapist.
Substanceabusermaintainsprimaryresponsibilityforchanginghis behavior.
The goalofthisapproachiseithermoderationandharmreductionor abstinence.
Thetrainingconsistsofeightsequentialsteps:
1.Establishalimitonthenumberofdrinksperdayandthepeakbloodalcohollevelforalldrinkingoccasions.
2.Begintoself-monitor boththenumberofdrinkstaken andthedrinkingsetting(thisprovidesthe basisofafunctional analysis).
3.Modifytherate atwhichalcoholisconsumed.
4.Developandpractice assertivedrink-refusalskills.
5.Establishareinforcementsystemtorewardtheachievementof drinking-relatedgoals.
6.Determinethesocial,emotional,andenvironmentalantecedentsthatpromptoverdrinking.
7.Learnnewcopingskillsrather thanrelyondrinkingasameansofcoping.
8.Learnways to avoid relapse.
Research
TIP 34isbasedonresearchstudiesfromthe1960s tothe1990s. Substantialresearchsupportstheeffectiveness ofbehavioralapproaches.
Behavioraltheorieshaveledtointerventionsthathavebeenindividually proventobeeffectiveintreatingsubstance abuse.
Somepositiveresearchoutcomesresulting fromthesebehavioraltherapy approacheshaveincluded:
1.Decrease in the frequency of positive drug urines
2. Reported decrease in craving for substances
3. Significant increase abstinence
4. Maintained attendance at job-skills training programs
5. Decrease in days of drinking
6. Decrease in days of homelessness
7. Increase in days of employment
ResearchonContingencyManagementVoucher Systemsrevealed that:
1.Receivingvoucherscontingentoncompleting objective,individuallytailoredgoals related toone’soveralltreatmentplanwasmoreeffectivethan eitheravouchersystemspecificallytargeting drug-freeurinesamplesorastandardtreatmentwithouteither of thesecontingency contractsadded.
2.ClientsinaCRA-plus-vouchers conditionremainedintreatment longer,hadmorecontinuousweeksofdrug-freeurinesamples,and hadgreateramountsofcocaineabstinence,evenata12-month follow-up.
3.Nearly25%ofclients inatake-home incentive programmetthecriterionformarked reduction indruguse andalso weresignificantlymorelikelytoachieve thecriterionofhavingfourconsecutiveweeks ofdrug-freeurinesamples.
4.Clientsinanincentive programdecreaseduse by14-18%.
Thereareweaknessesintheresearchregardingbriefbehavioral therapy:
1.Some criticsarguethatresearchonbehavioralapproacheshasbeendeveloped undercontrolledconditions,andthatin“real”therapytherearemanymorevariablesatworkthancanbemeasuredincontrolledexperiments.
2.Behavioralself-controlapproacheshavebeenusedprimarilywithalcoholproblemsandmoreresearchisneededregardingitsuse withother substance abuse disorders.
3.Less evidenceisavailable concerningtheeffectivenessof contingencymanagementapproachesinthetreatmentofalcoholproblems.
Types of Settings and Clients
Briefbehavioraltherapycanbeusedwithclients before, during,andaftersubstanceabusetreatmentinindividual,group,andfamily settings.
Ifaclienthas certainexpectationsoftherapythat makeitdifficultforhim/hertocommittothegoalsandproceduresofbrieftherapyortoaparticulartherapeuticapproach,otherapproachesshouldbeconsidered orareferralmade.
Briefbehavioraltherapiesareapplicableinawiderange of substance abuse settings:
1.Outpatient
2.Inpatient
3.Individualtherapy
4.Groupsettings
5.Aspartofanintensivephase of treatment
6.Aspart of lessintensiveaftercareorcontinuingcare
7.Compatiblewithself-helpgroups
8.Compatible withpharmacotherapy
Applications in Substance Abuse Treatment
Thereissubstantialempiricalandscientificevidence insupport oftheeffectivenessofbehavioralapproaches.
Itisalsosoundlygroundedinestablishedpsychological theory.Itisderivedfromscientificknowledgeandapplied totreatmentpractice,andisstructuredinitsguidelinesforassessingtreatmentprogress.
Briefbehavioraltherapyismoreeffectivethan beingonawaitinglist,anditcouldbenefitmanyclients.Itisalsoflexibleinmeetingspecificclientneeds.
Itempowersclientstomaketheirownbehaviorchange,andisreadily acceptedbyclients dueto thehighlevelofclientinvolvementintreatment planningandgoalselection.
Duration of Therapy
Decisionsabout thelengthoftreatmentaremadeonthebasis of assessments,rather than accordingtoaformulaortheoretical assumptionabouthowlongtherapyshouldtake.
Insomeprograms,durationoftherapyisdeterminedmutuallybytheclientandtherapist.
Briefbehavioraltherapymaybethe bestoptioniftheclientobjectstolongertreatmentorifexpenseisanissue.
Theduration ofbriefbehavioraltherapiesisreportedtobeanywherefrom1 - 40sessions,withthetypicaltherapylastingbetween6- 20sessions.
Twentysessionsisusuallythemaximumbecauseoflimitationsplaced bymanymanagedcareorganizations.
Thebriefbehavioraltherapiesdescribedheremayinvolveasetnumber ofsessionsoraset range(e.g.,from6-10 sessions),buttheyalwaysworkwithinatimelimitationthatiscleartoboththerapistandclient.
Themajorityofclients intherapy(regardlessofthemodality)remain in treatmentforbetween 6-22 sessions;90%endtreatmentbeforecompleting20 visits.
Evaluation of Effectiveness
Behavioral therapy focusesmoreonidentifyingandchangingobservable, measurablebehaviors.
Treatmentislinkedtoalteringthebehavior,and success isthechange, elimination,orenhancementofparticular behaviors.
Regularassessmentandmeasurementofprogressareintegralto effectivebehavioraltherapy.
Effectivenessevaluationsdonothavetobetime-consumingor complicated.Theycanbeconductedinperson,byphone, throughthe Internet, orbymail.
Theeffectivenessofbriefbehavioraltherapycanbeevaluatedby:
1.Clientparticipation
2.Treatmentadmissions
3.Discharge againstmedical advice rates
4.Clientsatisfactionsurveys
5.Follow-upphone calls
6.Counselor-rating questionsaddedtotheclinicalchart
TimeClock
Trainer Notes
Participant Workbook
Module 5 - Section 3
Strategy Identification Exercise
Time: 10 Minutes
Trainer Notes
■Turnoffallnoisyaudio/visualequipmentduring smallgroupdiscussions.
■Beawareofanyexternalandinternaldistractionsfromthesmallgroupdiscussions.
Thetrainerpreparesparticipantsforthestrategyintegrationprocess.Thepurposeofthisprocessistoencourageparticipantstodevelop newtherapeuticskillsfor workingwiththeirclients.
Thetrainerinvitesparticipantstothinkaboutaparticularclientthatwouldlikelybenefitfromabrieftherapy.
TheparticipantsreviewthehandoutfortheStrategyIdentificationExercise.Thishandoutpresentslistsofstrategiesofthemoduletopic,usuallyorganizedaccordingtothebasicconceptualmodelspresentedintheSummaryGrid.
Thetrainerdirectstheparticipantstoplaceacheck(√)nexttostrategies s/hehas used successfullyinhis/herpractice,andtoplace astar (*)nexttonewstrategiess/hewantstoincludeinhis/herclinicalpractice.
WhiletheparticipantsworkoncompletingtheStrategy IdentificationExercise,thetrainerisavailabletorespondtoquestionsandmoves about theroomtohelpparticipants.
Thetrainerfacilitatesawhole-groupdiscussionaboutthisexercise,askingparticipantstosharewhichstrategiestheyhavesuccessfullyused withagencyclients.Participantscanlateruse staff memberswithsuccessfulexperiencestohelpthemintegrateanewstrategyintotheirownpractice.
Participant Workbook
■BriefBehavioralTherapyBasedonOperantLearningStrategy IdentificationExercise
Trainer Script
Strategy Identification Exercise
Thepurposeofthistrainingistointegratenewskillsforbrieftherapyintoourprofessionalpractice.
Youwillbeginthisprocessbyidentifyingonenewstrategythat you believewill behelpfulforoneofyourcurrent clients.
GroupExercise
PleasereviewtheStrategyIdentificationExerciseforBriefBehavioral
TherapyBased onClassicalConditioninghandout.
Thehandoutpresentslists ofbriefbehavioraltherapystrategies. Strategiesarepresentedaccording tothemodelsdiscussedearlier:
1.FunctionalAnalysis
2.ContingencyManagement
3.WrittenContracts
4.BehaviorContracting
5.CommunityReinforcement
6.BehavioralSelf-ControlTraining
Strategiesfortheinitialandlatersessions arealsoincluded.
Thehandoutdirectsyoutoplaceacheck(√)nexttostrategiesthat youhaveusedsuccessfullyinyourpractice,andtoplaceastar(*)nexttonewstrategiesthat youwouldliketoincludeinyourclinicalpractice.
Aftercompletingthisportionoftheexercise,youselectonenewstrategy(fromthestrategieswithastar)touse withacurrentclient.
Thisexercisegivesusanopportunitytosharesuccessfulexperienceswehavehadwiththesebrieftherapystrategies.
Pleasepayclose attentiontotheexpertiseofourstaff thatisrevealedinthisexercise.Youmaywanttorecruitthem tohelpyouwithyour newstrategy.
Who would liketoshareyoursuccessfulbrieftherapyexperienceswithus?
Module 5 - Section 4
Strategy Identification Mind-Map Exercise
Time: 10 Minutes
Trainer Notes
■Turn off all noisy audio/visual equipment during small group
discussions.
■ Be aware of any external and internal distractions from the
small group discussions.
Participants work individually to complete this section.
WhiletheparticipantsareworkingontheStrategyIntegration
Mind-Map,thetrainer isavailabletorespondtoquestionsand
movesabout theroomtohelpparticipants.
The use of colored pencils or crayons with this exercise helps to enhance an atmosphere of creativity for brainstorming. Brainstorming is for developing ideas, not for evaluating them. The trainer encourages participants to help one another with a nonjudgmental attitude.
When most of the participants have completed the mind-map, the trainer may invite volunteers to share their strategy and plan with the rest of the group. Maintaining the group rule regarding respect is very important in this discussion so as not to discourage a participant from executing his/her plan.
Participant Workbook
■ Strategy Integration Mind Map
Trainer Script
Strategy Identification Mind-Map Exercise
You will develop a plan of action for utilizing your new strategy and evaluating its effectiveness. The Strategy Integration Mind-Map Exercise is used for this purpose. This is in your handout packet.
The purpose of the Strategy Integration Mind-Map is to develop a plan into your clinical practice.
You should select the ideas that are the best and most appropriate for your client. Do not put the name of your client on this form. However, you may want to include this strategy in your client’s treatment plan.
Mind-Mapping Directions
This exercise is a mind-map. Mind-mapping allows you to conceptualize the integration of a new strategy on one page, and in a manner that is more easily remembered than other forms of writing, such as outlines or lists.
It uses brainstorming to encourage the generation of new ideas, and allows you to organize your thinking by fitting ideas together into a conceptual “map.”
You can write or draw your ideas. You can have fun and be creative while you develop your ideas. The use of colors can help to separate different parts of your map. By personalizing the map with symbols and designs, you can develop a strategy that will be more easily remembered and used with your client.
All ideasonthemind-maparerelated tothethemeinthecenter.The ideasareconnectedtothecentral themeortooneanotherwithlines orarrowstoindicatetheirrelationship.Keyideasforthestrategy mind- maparesuggestedontheborderoftheexerciseform.
Writeyourselectednewstrategyinthecenter ofthemind-map,andthen–usingpens,coloredpencils,orcrayons–place related ideasin boxes,circles, lists,ordrawingsthatradiate fromthecenter.
Wouldanyonevolunteer tobrieflyshareyourstrategyandmind-mapwiththerestofthegroup?
Module 5 - Section 5
Assignments and Closing
Time: 3 Minutes
TimeClock
Trainer Notes
Participant Workbook
Trainer Notes
Thetrainer givesabriefpreviewofthenexttrainingtopic.
Thetrainer distributesthehandoutpacket forthenexttrainingsession, andencouragestheparticipantstoreadtheSummary GridandStrategyIdentificationExercisebeforethetraining.
Thetrainerdiscussesdate,time,andplaceofthenexttrainingsession. ThetrainergivesTIP 34 readingreferencesforthistraining.
Participant Workbook
■Handout PacketforNextTIP 34 Training
Trainer Script
Reading and Homework
ThankyouforparticipatinginthisTIP34Training Program.
Ournexttrainingmodulewillexplore [Training Topic]. Pleaseread theSummary GridandcompletetheStrategyIdentificationExercisebeforethetraining.
TheTIP 34 referencesforthistrainingare _____[relevant].
TIP 34pagesorchapter].
Thistrainingmodule isscheduledfor [date,time,and place].
Participant
Workbook
Module 5:
Brief Behavioral Therapy Based
on Operant Learning
Brief Behavioral Therapy Based on Operant Learning
Summary Grid
Key Concepts
■Humanbehaviorislargelylearned,ratherthan determinedbygeneticfactors.
■Behaviorislargelydeterminedbycontextualandenvironmentalfactors.
■Changesinbehaviorcome aboutthroughlearningnewbehaviors.Thesamelearningprocessesthatcreateproblem behaviorscanbeusedtochangethem.
■Substanceabuseisalearnedbehaviorpattern,andsubstanceabusedisordersaredeveloped and maintainedthroughthegeneral principles oflearningandreinforcement.
■Changingthereinforcementcontingenciesthat governsubstanceabusebehaviorcanmodifyit.
■Substanceabusebehaviorcanbechangedbyteachingtheclientmoreadaptive,alternativebehaviors aimed atachievingthesamerewards.
■Thecornerstoneofadequatetreatmentisathoroughbehavioralassessment. Eachclientisuniqueandmustbeassessedas anindividualinaparticularcontext.
■Actuallyengaginginnewbehaviorinthecontextinwhichitistobeperformedisacriticalpartof behavior change.
■Theaimoftherapyistohelptheclientaddressspecific,identifiableproblemsinsuchawaythattheclientisabletoapplythebasic techniquesandskillstotherealworld,withouttheassistance ofthetherapist.
Models
■FunctionalAnalysis:
1.Specifically,itexaminesthestimulithattriggeruse,theconsequencesthatfollow,themeaning ofthebehaviortotheclient,aswellaspossiblemotivatorsandbarrierstochange.
2.Inbehavioraltherapy,thisisthe firststepinprovidingtheclientwithtools tomanageoravoid situationsthattriggersubstance use.
3.Functionalanalysisyieldsaroadmapofaclient’sinterpersonal,intrapersonal,andenvironmental precursors,catalystsandreactionsto substance use.
4.Itprobesthesituationssurrounding theclient’ssubstance abuse.
■ContingencyManagement:
1.Thegoalistochangethoseenvironmentalfactors(contingencies)thatcaninfluence substance abusebehaviorbydecreasingorstoppingsubstanceuse andincreasing behaviorsthat areincompatiblewithuse.
2.Contingenciesthat promptaswellasreinforcesubstanceabuseareidentifiedthrougha functionalanalysis.
3.Targetedcontingenciesareweakenedbyassociatingevidenceofsubstanceuse (e.g.,adrug-positiveurinescreen)withsome formofnegativeconsequenceorpunishment.
4.Contingenciesthatpromptandreinforcebehaviorsincompatiblewithsubstance abuse andthatpromoteabstinencearestrengthenedbyassociatingthem withpositivereinforcers.
5.Contingencymanagementproceduresareoftenembeddedinacomprehensivetreatmentprogram,and oftencombined withmorecomprehensiveapproaches,suchascommunityreinforcementandbehavioral self-controltraining.
■BehaviorContracting:
1.Theactofcomposingandsigningacontractisasmallbutpotentiallyimportant ritualsignifyingtheclient’scommitmenttotheproposedchange.
2.Contractsthattarget goalssupportiveofrecoveryaregenerallymorelikelytobeachieved andleadtobetter outcomesthanthosemoredirectlyrelated tosubstance use.
3.The effectiveness ofsuchcontractsalsoappeartobelinkedtotheseverityoftheconsequencesthatmightresult fromabrokencontract.
4.Behavioralcontractsareoftenembeddedinacomprehensivetreatmentprogram,andoften combinedwithmorecomprehensiveapproaches,such as communityreinforcementandbehavioral self-controltraining.
■CommunityReinforcementApproach(CRA):
1. CRAwasoriginallydevelopedasatreatmentforalcoholabusedisorders.
2. CRAisabroad-spectrumapproachbasedontheprinciples ofoperantlearning.
3.ThegoalofCRAistoincreasethelikelihoodofcontinuedabstinencefromalcoholordrugsby reorganizingtheclient’senvironment.
4.Environmentalreorganizationisachieved byincreasingtheavailabilityandfrequency ofreinforcementsderivedfromalternativevocational,family,social,andrecreationalactivities,particularlyactivitiesthat areincompatiblewithsubstanceabuse.
5.These alternativeinterpersonalandsocialactivitiesaremadeavailablewhentheclientissober ordrug-free,butmadeunavailableiftheperson drinksorusesdrugs.
6.Alternativereinforcementscanbetailored tothespecificcircumstancesofaclient.
■BehavioralSelf-ControlTraining:
1.Thegoalofthisapproachiseithermoderationandharmreduction orabstinence.
2.Thetrainingconsistsoftheeightsequentialsteps:(1)Establishalimitonthenumber of drinksperdayandthepeak bloodalcohollevelforalldrinkingoccasions;(2)Begintoself- monitor boththenumber ofdrinkstaken andthedrinkingsetting (thisprovides the basisofa functionalanalysis);(3)Modifytherateatwhichalcoholisconsumed;(4)Developandpractice assertivedrink-refusalskills;(5)Establishareinforcementsystemtorewardtheachievement ofdrinking related goals; (6)Determinethesocial,emotional,andenvironmentalantecedents that promptoverdrinking;(7)Learnnewcopingskillsratherthanrelyondrinkingasameansof coping;and(8)Learnwaystoavoidrelapse.
3.Thisapproachfocusesonthesubstanceabuserandhis/herattemptstoreduce orstop substanceabusealone orwiththeaidofatherapist.
4.Thesubstance abuser isgivenprimaryresponsibilityforchanginghisorherbehavior.
Research
■Substantialresearchevidence supportstheeffectivenessofbehavioralapproaches.
■Behavioraltheorieshaveledtointerventionsthathavebeen individuallyproventobeeffectivein treatingsubstance abuse.
■TheCommunityReinforcementApproach(CRA)isamong thoseinterventionshavingthegreatestempiricalsupport.TheapplicationofCRAstosubstancesother thanalcoholalsoappearstohavebeen successful.
■Thereisgoodempiricalsupportforbehavioralself-controltraininginachievingthegoalof moderate,non-problematicdrinking.
■PositiveResearchOutcomes:
1.Decreaseinthefrequency ofdrug-positiveurines
2.Reported decreasedcravingforcocaine
3.Significantlyincreasedcocaineabstinence
4.Maintainingattendanceofmethadoneclientsatajob-skillstrainingprogram
5.Fewerdaysofdrinking
6.Fewerdaysof homelessness
7.Moredaysofemployment
■ ResearchonContingencyManagementVoucherSystemshaverevealed:
1.Receivingvoucherscontingentoncompleting objective,individually-tailoredgoals related toone’s overalltreatmentplanwasmoreeffectivethan either avouchersystemspecificallytargeting drug-free urine samplesorastandardtreatmentwithout either of thesecontingency contractsadded.
2.Clientsina CRA-plus-vouchers conditionremainedintreatmentlonger,hadmorecontinuousweeksof drug-freeurinesamples,andhadgreateramountsofcocaineabstinence,evenata12-monthfollow- up.
3.Clientsinacontingent voucherconditionalsodemonstratedanincreased abstinencefromopiates.
4.Nearly25% ofclients inthetake-home incentive programmetthecriterionformarkedreduction indruguse andalso weresignificantlymorelikelytoachieve thecriterionofhavingfourconsecutiveweeks ofdrug-freeurinesamples.
5.Clientsinanincentiveprogramdecreasedusebetween 14 –18%.
■Researchweaknesses
1.Some criticsarguethatresearchonbehavioralapproacheswasdevelopedundercontrolledconditions,andthat in“real”therapytherearemanymorevariablesatworkthancanbemeasuredincontrolledexperiments.
2.Lessevidenceisavailable concerningtheeffectivenessofcontingency managementapproachesinthetreatmentofalcoholproblems.
3.Behavioralself-controlapproacheshavebeenusedprimarilywithalcoholproblems,andmoreresearchisneededregardingitsusewithothersubstanceabusedisorders.
Types of Settings and Clients
■Briefbehavioraltherapycanbeused withclientsbefore, during,andaftersubstance abusetreatmentinindividual,group,andfamilysettings.
■Brieftherapiesareapplicableinawiderange ofsubstance abusesettings:
1.Outpatient
2.Inpatient
3.Individualtherapy
4.Groupsettings
5.Aspartofanintensive phaseoftreatment
6.Aspartofless intensive aftercareorcontinuingcare
7.Compatible withself-helpgroups
8.Compatible withpharmacotherapy
Applications in Substance Abuse Treatment
■Flexibleinmeetingspecificclientneeds.
■Readilyacceptedbyclients duetothehighlevelofclientinvolvementintreatmentplanningandgoalselection.
■Soundlygroundedinestablishedpsychological theory.
■Derivedfromscientificknowledgeandapplied totreatmentpractice.
■Structuredinitsguidelinesforassessing treatmentprogress.
■Empowersclientstomaketheirownbehaviorchange.
■Showntobeeffective,according tostrong empiricalandscientificevidence.
Duration of Brief Therapy
■Decisionsabout thelengthoftreatmentaremade onthebasis of assessments,rather than accordingtoaformulaortheoreticalassumptionabouthowlongtherapyshould take.
■Insomeprograms,duration oftherapyisdeterminedmutuallybytheclientandtherapist.
■Briefbehavioral therapymaybethebest optioniftheclientobjectstolongertreatmentorif expenseisanissue.
■Thedurationofbriefbehavioraltherapiesisreported tobeanywherefrom1- 40sessions, withthetypicaltherapylasting6 - 20 sessions.
■Twentysessionsisusuallythemaximumbecauseoflimitations placed bymanymanagedcare organizations.
■Thebriefbehavioraltherapiesdescribedhere mayinvolveaset numberofsessionsoraset range(e.g.,from6-10 sessions),buttheyalwaysworkwithinatimelimitationthatiscleartoboththerapistandclient.
■Themajorityofclients intherapy(regardlessofthemodality)remainintreatmentbetween
6 - 22 sessions;90% endtreatmentbefore completing 20 visits.
Evaluation of Effectiveness
■Behavioraltherapyfocusesmoreonidentifyingandchangingobservable,measurablebehaviors
■Treatmentislinkedtoalteringthebehavior,andsuccessisthechange,elimination, orenhancementof particularbehaviors.
■Regularassessmentandmeasurementofprogressareintegraltoeffectivebehavioraltherapy.
■Evaluations canbedone simplyandefficientlywithoutrequiringexcessivestaff timeandenergy,orintegrated intoroutine clientcontacts.
■Effectivenessevaluationscanbeconductedinperson,byphone,throughtheInternet, orby mail.
■Theeffectivenessofbrieftherapycanbeevaluatedby:
1.Clientparticipation
2.Treatmentadmissions
3.Dischargeagainstmedical advice rates
4.Clientsatisfactionsurveys
5.Follow-upphone calls
6.Counselor-rating questionsaddedtotheclinicalchart
Strategy Identification Exercise Brief Behavioral
Therapy Based on Operant Learning
■Placeacheck(√)nexttostrategiesthatyouhaveusedsuccessfullyinyourclinicalpractice.
■Placeastar(*)nexttonewstrategiesthatyouwanttoinclude inyourclinicalpractice.
Functional Analysis:
●Evaluate(1)thenumberandtypeofhigh-risksituations,(2)thetemptationtouse inthese situations, (3) confidencethat onewillnotuseinhigh-risksituations,(4)substanceabuse-relatedself-efficacy, frequencyandeffectivenessofcoping,and(5)substance-specific effect expectancies.
●Identifytheantecedentsandconsequencesofsubstanceabusebehavior,whichserveastriggerand maintenancefactors(antecedents of usecancomefromemotional,social,cognitive,situational/environmental, andphysiologicaldomains).
●Focusonthenumber, range,andeffectivenessoftheclient’scopingskills.
Contingency Management:
●Urinesamples
●Vouchers
●Take-HomeIncentives (e.g.,methadonetake-home privilegescontingent ondrug-freeurinesamples)
●Take-HomeMedicationIncentives
●RemainintheWork;RemainintheTherapeuticHousing
●JobTraining/WorkPrograms
●Abstinence-ContingentPrograms
●Naturalistic Contingencies(threatenedloss of job, spouse,ordriver’slicense).
Written Contracts:
●Clearlyspecify—usingtheclient’sownwords—the target behaviortobechanged,thecontingencies surroundingeither changingbehaviorornot,andthetimeframeinwhichthedesiredbehavior changeisto occur.
●Includecontingencies,especially rewards orpositiveincentives,that willreinforcetarget behaviors(e.g., attendingtreatmentsessions,gettingto12-Stepmeetings,avoidingstimuliassociatedwithsubstance use).
●Developclearlydefinedgoals that arebrokenintosmallsteps,occurfrequently,andrevised as treatmentprogresses.
●Contingenciesshould occurquickly after successorfailure.
Behavior Contracting:
●Improvevocational behavior
●Savemoney
●Bepromptforcounselingsessions
●Takemedicationregularly
●Providecleanurinesamples
Community Reinforcement:
●VocationalCounseling
●Job-Seeking Skills (e.g.,résumédevelopment,applicationcompletion,jobinterviewskills)
●SocialandRecreationalCounseling
●MaritalCounseling
●CommunicationSkillsTraining
●Problem-SolvingTraining
●Drink/DrugRefusalSkills Training
●CommunityReinforcementandFamilyTraining
Behavioral Self-Control Training:
●Moderation
●Reduction of Risk
● Abstinence
●Stress Management
● Coping Skills
● Programmed Therapy
● Writing Therapy
● Self-Help Manuals
● Correspondence
● Computer Programs
● Homework Assignments
During Initial Session:
●Engagetheclientinacollaborative process.
●Explorethereasonstheclientisseekingtreatmentatthisparticulartime.
●Exploretheextenttowhichthismotivationfortreatmentisintrinsic,rather than influencedbyexternalsources.
●Exploretheareasofconcernthattheclientandsignificantothersmayhaveabouthis/her substance abuse.
●Explorethesituationsinwhichhe/shedrinksorusesexcessively,andtheconsequenceshe/sheexperiences(bothpositiveandnegative,aswellasproximalandremoved fromtheactual substanceabuse).
●Conductanabbreviatedfunctionalanalysis.
●Determinetheantecedentsthat promptsubstance abuse,andthereinforcersthat appeartomaintainit.
●Begintoformulate atreatmentplan.
●Identifybehaviorsincompatiblewithheavydrinkingthat shouldbereinforcedandtargetedforanincreaseinfrequency.
●Notethemost salientproblemsidentifiedbytheclientandintervene withthemfirst.
●Assesstheclient’sreadinesstochangeandthen developinitialbehavioralgoalsincollaborationwiththeclient.
●Assist theclientinimprovingdailyfunctioning; reviewproceduresfor filling outself-monitoringrecords.
●Provideself-help manuals;Providehomeworkassignments(keepingajournal ofbehaviors, activities, and feelingswhenusingsubstancesoratriskofdoingso).
●Make“homework”thecentral concernofthetherapy session.
During Later Sessions:
●Reviewtheinformation collectedthroughself-monitoring
●Negotiateabout treatmentgoals
●Considertheintroductionofcueexposuretrainingorrelapse prevention
●Involvetheclient’sspouseorsignificantothers
●Involveasignificantother inbehavioralcontractingandcommunityreinforcementinterventions
●Developacontingency contractwiththeclientandthesignificantother