Hello everyone and welcome back. In our last section we talked about some different aspects of biological approaches to treatment. In this section we are going to talk about some psychological approaches.

Let's begin by going to slide two. First of all as we can see here there is a wide variety of approaches that use psychological techniques. It encompasses a wide variety of theoretical models. Techniques used from psychology have also been incorporated by a wide variety of other models, as well.

In general as we see in slide three there is a wide variety of approaches one uses within psychological treatment. These include classical and operant conditioning approaches cognitive approaches as well as others.

Let's talk a little bit about aversion therapy in relation to substance abuse treatment. As we can see in slide four Aversion therapy was first developed and refined by Schick-Shadel Hospital in Seattle. Basically, what it uses is a classical conditioning model.

So let's walk through classical conditioning again just for a few moments to give us a little review. As we can see in slide five in classical conditioning we have some kind of unconditioned stimulus causing an unconditioned response. We then pair that unconditioned stimulus with a conditioned stimulus which gets an unconditioned response. Over a period of time the conditioned stimulus elicits a conditioned response.

Of course there are related aspects as well. As we see in slide six we have generalization where similar stimuli to the original conditioned stimulus cause a conditioned response. And we also have extinction where after repeated exposures does not cause a conditioned response.

Further, after we have some delay between the responses, basically you wait for a period of time, present the conditioned stimulus again and you get spontaneous recovery. Again the conditioned response occurs but it is in weaker form. And finally, of course we have opponent process which basically says that when the conditioned stimulus is presented with a UCS the opposite response occurs. Present the US with no CS you basically get a B state still occurring and you get craving and withdrawal. All of this stuff we have talked about previously.

So how does all that relate to aversion conditioning? As we can see in slide eight, what Shadal Hospital did was something very interesting. They took a drug that caused nausea and vomiting, and that drug was called Emetine. So you get Emetine, you give the Emetine; the person gets nauseated and vomits. It is not just a little bit of vomiting, it is projectile vomiting, and it’s all over the place. What you then do is pair alcohol with the Emetine. So you give some alcohol, then you give the Emetine, you get nausea and vomiting and over a period of time you get alcohol alone causing nausea and vomiting. In addition to that, generalization also occurs. So similar stimuli will also cause nausea and vomiting as well. So the sight of the alcohol, the smell of the alcohol, etc will also elicit the nausea and the vomiting response.

What is the procedure for aversion conditioning? As we can see in slide nine the first thing you do is a thorough medical and assessment workup. You detoxify the client as needed. The client then has four to six aversion treatments every other day over a two week period. On the off days the client then participates in groups, family therapy, and a wide variety of other things.

Now once the client has gone through the session. What Shadal has found is that you need to come back for follow up sessions. So what the client does is return for follow ups when there is a high probability of relapse. As we see in slide ten, these relapse days occur about day ten, day thirty, day sixty, ninety, and one hundred eighty days. What the client then does is about day ten they come in and get what they call a booster session. So basically you experience the same procedure. This keeps the conditioning at a high level and decrease the probability of the person going out and using again. Often times as well, the centers will also allow the client to return at any time if the client needs some kind of a booster session between the other times.

Now initially with aversion conditioning, the therapy focused primarily on the aversion. However, as we can see in slide eleven they began to include a variety of other therapeutic interventions as well.

So, how good is it? As we can see in slide twelve when one goes and examines the results of the treatment it gives you the highest rates of success in the addictions business. Sixty to seventy percent abstinence rates at four year follow-up, which is unbelievable in relation to addictions treatment. So the question then becomes why, and what are some of the issues associated with that?

The first issue as we can see in slide thirteen is that it is very expensive. It costs ten to fifteen thousand dollars for an individual to go through this type of treatment. This may or may not be covered by insurance. Aversion conditioning also cannot be used by some individuals, such as the elderly who may have medical problems, or some other kind of intervention. The intervention also requires an inpatient stay and the procedure also receives a lot of negative publicity or a lot of flack. Consequently, a lot of people do not like to use this kind of procedure even though it gives you the best success rates. Now there is also a variable that goes along with that. Some individuals will say that it is a client selection process and that may be true. But regardless of whether one has a selection bias or not success rates are still very, very high regardless of that selection bias.

Now there was another aspect that went along with this aversion conditioning process and this is shown in slide fourteen. Basically, the idea was this, we have emetine and it is working okay for us to get aversion. What if we made the aversion procedure very, very intense? So let's make it very, very scary and very, very, intense for the client. So what the researchers and aversion therapists did was that they changed the drug. They changed the drug to Scopolamine.

So, what does Scopolamine do? As we can see in slide fifteen, Scopolamine stops your breathing and elicits a major fear response. The alcohol was then paired with the Scopolamine. So you give the alcohol with Scopolamine, you stop breathing, and you get fear. And, over a period of time the alcohol was then given alone and low and behold, no conditioning occurred. The question then become why? Why did this version of aversion conditioning not work?

The answer was, as seen in slide sixteen, was that the focus was on the fear response. That is, when you can not breathe you are not thinking about alcohol what you are trying to think about is trying to breathe. As a consequence of that, you were not thinking about the alcohol at all and as a result the level of conditioning was decreased.

So in conclusion, as seen here in slide seventeen, aversion therapy can be very effective and is in fact quite effective at stopping alcohol consumption however it has some issues that one needs to consider when one is using it.

So what about some other types of psychological models in relation to addictions treatment. Well, as we can see in slide eighteen we also have operant conditioning models as well. Basically what operant conditioning models rely on are the aspects of reinforcement and punishment. As we know from previous discussions is basically that you have some kind of stimulus which causes a response and is followed by some kind of consequence stimulus. As a result of that the behavior increased or decreased. What the operant theorist contends is that alcoholism is like any other behavior that is out there. You change the environmental conditions and the behavior then changes.

So what the operant theorist tried to do was use a couple of other types of procedures. The first one of these major procedures is shown in slide nineteen. And that is what is called Controlled Drinking Procedure. The idea behind controlled drinking is that the individual has some kind of stimuli that causes the person to drink out of control. Those stimuli are then reinforced and that then causes the out of control drinking to continue. What controlled drinking advocates say is this, what we need to do is identify the stimuli that contributes to the person drinking out of control. And then reinforce stimuli that does not cause out of control drinking and punish stimuli that contributes to the out of control drinking.

So what are some of the behaviors to reinforce? Some of these are listed on slide twenty. Sipping drinks, spacing drinks between each time you have something. Alternating drinks, that is, you have alcohol then maybe you have a diet soda. Eating food with drinks, drinking only during certain periods of time like drinking in only certain social situations, and a wide variety of other stimuli. This would then cause the person to reduce their consumption and their alcoholic drinking.

So what types of behaviors do we punish? As we see in slide twenty-one, gulping of drinks or having multiple drinks one after another, drinking alone, drinking in bars, getting drunk, all these different behaviors have some kind of punishment contingency that went along with them.

Now one of the major aspects that went along with this was a variety of studies done by Allen Marlat, and Miller, and others. What they would do was develop what they called a Bar Laboratory which is exactly like a drinking establishment in the local community. What these bar laboratories would do be to identify the stimuli that the person had with drinking. As we see in slide twenty-two, the person would then drink with their particular peers. They would then be reinforced for appropriate behavior and punished for inappropriate behavior. As a consequence the alcohol drinking behavior decreased and the social behavior would then increase.

The problem was that if you do not provide the reinforcement or the punishment or you stop providing the reinforcement or the punishment, as we see in slide twenty-three the drinking behavior goes back to the alcoholic drinking again. So basically the whole issue behind extinction is that when you stop providing the reinforcers you go back to the original behavior. So the procedures needed to taken into account this extinction process and those programs that were successful did so.

Now there is a wide variety of other aspects using operant approaches as well. Some of these were used in inpatient models such as Shuckets Model and others were using with outpatient models. The thing about the controlled drinking studies and the controlled drinking aspects was that these controlled drinking studies were not appropriate for anyone. It may be appropriate for a person that is twenty-one or a person who has tried multiple abstinence programs.

But as we can see in slide twenty-five, it may be inappropriate for use with individuals with health problems, or having legal problems, or who become aggressive when using alcohol and it is definitely inappropriate with other drugs. Do controlled drinking or controlled other models when one is trying to control the behavior when one is still using has some issues that one has to work with before one begins to use this intervention.

Another group of models associated with psychological treatments is the cognitive models. Basically, what these models contend is that you need to focus on the internal aspects of the person to cause them to stop their use. As we can see in slide twenty-six, what the cognitive model theorists contend is that if you change the thought patterns of the individual the person will stop using the substance. The focus here is on the obsessions, compulsions, the underlying reasons, etc that underlie the treatment of addictive drinking. The focus, unlike the operant and classical conditioning models is not on the behavior instead it is on other aspects.

So cognitive model theorists rely on a wide variety of other things. As we can see in slide twenty-seven, they may focus on thought aspects related to relapse or have the person recall negative aspects of using as well as the positive aspects. May examine issues of depression related to not using. Giving up something you love is very, very difficult and sometimes that causes a person to continue using. Of course reviewing cognitive aspects related to craving, anxiety etc. And the therapist may also examine aspects related to emotion and concentration. Generally, regardless of approach cognitive models focus on a variety of different things. They are focusing on the internal aspects of the client and trying to change particular thought patterns.

What are some of the problems with cognitive approaches? As we can see in slide twenty-eight, all cognitive approaches do focus on those internal aspects. Consequently all of the approaches are correlational in nature. Some of the cognitive models have poor reliability and poor validity while others are much better researched and have much better results.

So in conclusion and as shown in slide twenty-nine, there are a wide variety of different psychological approaches to treatment. Most of the behavioral models and the newer cognitive models have been well researched and have high reliability and do quite well in relation to the field. Older behavioral models are not used as much and some are actively resisted. Cognitive approaches are used much more extensively today and they will probably be used a lot more in the future.

So in general there is a wide variety of different psychological models and they have made huge impacts in the addictions treatments success rates. However, as we see in slide thirty there also needs to be a lot more research used within psychological models to get even better effectiveness.

Well that concludes this section, in our next section we are going to begin talking about twelve step models. Until then we hope you enjoy your day and we are looking forward to talking with you soon.

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