Describe behavioral/behavioural therapy of

addiction/substance abuse.

Answer:
Behavior therapy is a therapy that is
conducted by a therapist that has been
trained for this. This therapy is based on the
notion that certain behavior (like an
addiction) starts by rewarding this behavior,
and that it is reduced by punishment. This
rewarding and punishing shouldn't be seen in
the literal sense of the words. A reward can
be that you win something from a slot
machine, that you get more friends by using
drugs, or that you feel better by smoking. In
other words, it is something positive
resulting from certain behavior. Punishment
can be that you have a terrible hangover and
feel bad after drinking, that you lose friends
because you use drugs, or that you have
debts because you gamble.
The therapy uses rewards and punishments
to achieve more good behavior (be
motivated, not using) and to reduce negative
behavior (relapse).
Rewards can consist of a night to the movies,
a new sweater, going out for dinner, a day
off, etc., when during a determined period of
time you have behaved well. Punishments
can consist of prohibition to receive visitors,
no extras, not being allowed to go home for
the weekend, or in worse cases informing
employers or a family member (with the
permission of the addict
Stopping Your Behavioral Addiction
Can I stop my behavioral addiction on my own?

Absolutely. I think the research suggests that most

people, in fact more than 5% of people do stop it on
their own. That means without a self-help book,
without a therapist, without a support group, without
anything. People evolve; see the severity of the
problems. They don't necessarily stop in one fowl
swoop but overtime there is subtle course
correction. Yes, I think that is step one. When
someone sees themselves having a problem they
should try to initiate changes before they sort of
bring in the big guns, the professionals, and see if
they can stop on their own. They have much more
power than they might assume. One of the
problems again with the disease model, is there is
an assumption, or the twelve step model, there is a
powerlessness concept and thereby suggesting you
cannot do anything on your own. I feel that is a very
dangerous method, to be frank. That saying the
addict cannot initiate self-corrective behaviors.
If I want to stop my behavioral addiction on my
own, what should be my first step?

The answer to what your first step in stopping your

behavioural addiction should be lies in the addiction
itself. What is it all about? As we've spoken about
before, the first thing I would recommend is, without
shame, without blame, and without putting yourself
down, stand back, get out a spreadsheet or a piece
of graph paper and start to just graph how often and
the frequency of when you engage in this particular
behaviour. Beyond that, there's a substantial
amount that you might do. That is, figure out what
times you typically engage in the behaviour. If you
look at an addict, generally speaking, they engage
in their destructive behaviour in a slice of hours.
Let's say 5:00 to 7:00, or early in the morning, or
something like that. Those are the hours that the
body has been taught (sort of like muscle memory)
to go and to engage in these sort of behaviours,
and the individual should try to find activities that
are inconsistent with the destructive addictive
behaviour. Another sort of strategy: they may go to
the self-help book section at their local library or
bookstore, they might go on the Internet and try to
get some basic knowledge about what might be
going on, they can consult a professional; a
psychologist or a physician who is specializing in
addiction. Let's just be frank. Most physicians have
no idea about addictions. They have a very
pessimistic view on being able to cure an addiction.
So, you need to seek out somebody who really
knows something about it, and don't be sort of
duped just because they have the name “addiction
specialist”; they may not know anything other than
one philosophy of addiction recovery. An addiction
specialist may only know 12-Step recovery. Another
addiction specialist, like myself, only knows
cognitive behavioural methods. So, you want to
shop around, if that's how far you go, and look for
methods that make sense to you; that you think you
can integrate into your lifestyle, that your family can
accept, and that you could hold onto well past sort
of the action stage where you're actually doing
something. This is a lifetime evolution you have to
conceptualise. This is not a little sprint where you're
just going to do a few little things here. This is sort
of a reformatting of what I do this hour, that minute,
when this happens. It's a way of coping in a much
broader sense than you might expect; much
broader than just the addiction itself.
Where should you go for help with a behavioral
addiction?

The unfortunate thing is that in this country there

are very few treatment resources for behavioural
addiction. There are some, but there are not a lot. If
you had a chemical addiction you'd find a treatment
resource, probably, on every corner. However, for
behaviour addictions, they're quite difficult to find. If
you're going to go about finding a recovery
programme and a more cognitive behavioural one,
probably the easiest one to identify is a private
clinician, private psychologist, social worker, or
mental health professional in your community. The
best place to find that is in your phone book or
information. You call up and you ask your local
psychological association as well as call up the
National Organization of Cognitive-Behavioural
Therapists or go online and look for a professional
within your community. Beyond doing private one
on one or private group, there are a few inpatient
facilities (not a lot) around the country. There are
some outpatient facilities; that means that you don't
go in, you don't check yourself in, and you don't
sleep there. There are support groups, although not
a lot. There's smart recovery, where the individual
wants an abstinence goal. There's moderation
management, which is for harm reduction goal, but
there are not a lot of support groups on that level.
However, there are Internet chat rooms and there
are Internet resources that aren't exactly formalised
support groups but you can get some accurate and
solid information on approaching it from a cognitive
behavioural standpoint.
What is "Moderation Management"?

Moderation Mangement is a 51C national self help

support group primarily dealing with alcohol
problems. But the principles of moderation
management can be applied to any behavioral
problem and any behavioral addiction. There is an
internet chat room and internet support and tools
and strategies that are available for someone to
look up online. It's free of charge. It's a new
paradign in the self help movement and the only
one I know of that approaches it from a harm
reduction standpoint.
What is an "intervention" in behavioral
addiction?

An intervention is a outgrowth of what's called the

Johnson Model of Addiction or the Johnson Model
of Treatment. It was developed about 45 years ago.
Basically, there's an assumption in an intervention
that the individual is diseased and therefore, does
not know what they say or does not know what they
do. Intervention is usually orchestrated by a trained
professional in intervention processes where they
will orchestrate the close family members, close
business people, friends—where they will come in
and sort of like surprise the addict and confront
them with issues revolving around their behavior.
Post that and, ideally in the intervention model, the
individual is willing and able to immediately go
directly to an inpatient facility. Immediately. There's
usually no postponement, and that's usually set up
even before the intervention. So a professional
comes in, has a couple of sessions with the families
and his friends, and then it's sort of like a surprise
party where they come in, and the addict walks in,
and they say, “Why don't you sit down?” And there's
a rehearsed sort of set of dialog followed by a set of
heartfelt emotional expressions by loved ones about
the problem and trying to break through the denial
that is seen or that is categorized as denial in the
disease models formulation. And hopefully the
addict will agree to go into a residential type
program.
How effective are interventions in dealing with
behavioral addiction?

I'm very sceptical about interventions in dealing with

behavioural addiction. I've worked at several
residential treatment centres. I believe that some
people really do respond well to interventions, but
the vast majority find them as providing more
reasons to put their heels into the ground and say:
"I'm not going to do what you tell me to do; I think
it's your problem, get off my back". Many people
I've seen in these residential centres may go in to
acquiesce to the family's requests. Then, two or
three days later, they accidentally find a way of
checking out, and two or three hours after they
leave the treatment centre, they're actively involved
in their addiction again, because they were not
sincerely involved in the choice of treatment. They
were not sincerely ready to involve themselves and
get serious about it, even though the family feels it's
time; it's time, it's gotten bad enough. If the
individual isn't ready, they're not going to integrate.
They're not going to take in the best, even the very
best, of treatment.
What is the most effective way to intervene in
behavioral addiction?

There are many ways to effectively intervene.

Please don't believe that you're powerless in the
face of your loved one's addiction. But my
recommendation is a much more soft approach, a
much more subtle approach, where maybe you sit
down on a Sunday afternoon and have sort of a
heart-to-heart discussion. You sort of say, "Maybe
the two of us should go and talk with a
professional." Don't make them feel guilty. Don't
make them feel diseased or they're mentally ill. But
rather help them see the cost benefit analysis. Help
them see that it's not a crisis yet but it's a building
up to a point. Some other organizations, like Al-
Anon, there's tough love approaches where the
individual is sort of like disengaged from if they
don't involve. Now, that's a strategy for intervention
that I'm not particularly supportive of. Can you
imagine your child having an internet addiction and
saying the tough love method, which means putting
them out on the street. I have met very few parents
that are willing to, you know, put the child out, put
the husband out of the house. But that is the tough
love approach. That is, again, another way to
intervene. For some adult males, it does seem to
motivate them and help them see that their behavior
has gone beyond what the spouse is willing to
tolerate. You shouldn't, on the other hand, endorse
or make light of how you really feel about the
addiction. So there's many ways of intervening.
What are the cognitive-behavioral types of
intervention?

There are several new cognitive-behavioural types

of intervention. They are not quite as dramatic and
drastic as the original sort of Johnson formulation
now available. One is called the Arise method, one
is called the Kraft method. These are acronyms,
and you could probably look them up on the internet
and find out further information. They approach it
from a very different standpoint. It's not all about
them being diseased, or about them being bad, but
rather approaching them from a much more gentle,
softer approach where there's much more
cooperation. For example, in the Kraft method,
between the husband and wife, there's more focus
on getting a job and using a certain sort of
pharmacological intervention. It's not all about
running off and getting fixed in that place called
rehab only to return to the same place. It's a much
more integrative approach. There may be certain
communities and community hospitals that have a
very distinct method that fosters more
communication that comes from a really loving
position where they want the relationship to
continue.
Who should intervene to stop a behavioral
addiction?

Generally speaking a formal intervention is always

done by a professional. So it would be the spouse,
it would be the parent that would retain the
interventionist and they would pay a fee. The
interventionist could arrive a few days earlier and
have these mock plays to go through. They would
sort of orchestrate the entire thing from A to Z. From
how the sequence of events happens and who says
what first and who says what second. So it's never
done by, or it's rarely done by the actual loved one,
it's done by an outside professional, but initiated by
a spouse or a parent.
What does it mean to "hit bottom" in behavioral
addiction?

The way one "hits bottom," or what "bottom" looks

like for person A versus person B, might be very,
very different. "Bottom" is nothing more than a
place, an activity, a time, where someone comes to
the realization that "this is as much pain and
suffering as I want to go through, and I want to
change. I'm willing to do whatever it takes." For
some people, it means getting in a car accident or a
DUI, or being diagnosed with liver failure. For
others, it's substantially less. I'm a big believer that,
yes, there is a bottom for everyone. I wish that it
wasn't so. Sometimes the bottoms are really low
bottoms. "Low bottoms" are: you lose your wife or
family, you lose your career, and you find yourself
out on the street. Or worse, your health has
deteriorated to the point where there's no
recoverability. Now hopefully no one waits to that
point, but often, many people do. There's also "high
bottom" people, and those are the people that I
really want to nurture to get the ball rolling. Where
things haven't come to the black-and-white "If I
don't get help now I'm going to die," but rather, see
the bottom coming, see the motion in that direction,
and sort of start reaching out for help or start
looking inside themselves, to start course
corrections, way before they get to that bottom
phase.
Thanks for watching video Stopping Your
Behavioral Addiction For more how to videos,
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Behavior.

Behavioral Addiction Treatment

What does "desensitizing" mean for a
behavioral addict?

We can use the scenario of everytime one sees a

video screen, one fantasizes about sitting down and
playing on it. This behavioural addiction is called
learned association, and desensitizing a
behavioural addict only means continuing to present
the object to the addict, the sensitized stimuli in
their presense, and teaching the addict a way to
relax in the face of being exposed to their addiction,
and over time desensitizing them to the learned
association between the video monitor and the
action of playing on it. In phobias, desensitizing is a
central technique where, for example, you were
sensitized to spiders, and you were very afraid of
spiders. During the first session a spider might not
even be brought into the room. During the second
session a spider may simply be discussed. During
the third session a picture might be brought in, but
all along the sufferer would be taught relaxation
techniques, so they would learn to relax in th
presence of a spider. Over time a real spider would
be brought in, and then brought a little closer to you,
a little closer to you and a little closer to you,
therefore desensitizing you to the stimuli.
How does a cognitive therapist work with a
behavioral addict?

Let's take two examples here, one being

pornography and one being gambling. How would
we desensitize someone to these sort of stimuli?
Let's take the pornography first: let's say every time
a person sees pornography, there's a sort of a "light
bulb" that goes on inside and they fantasize about a
woman or doing certain other things which brings
them into a further involvement with the
pornography. What we would do in the course of
treatment is exactly sort of what we've talked about,
but we would bring the images in and, in a slow,
progressive, predetermined sort of set of stages
where there may be a very obscure piece of
pornography, it may be a pornography of a very
mild type, and as we noted your arousal or your
stimulation from the pornography, we would ask you
to go through a relaxation technique. So, we would
start to teach you that this does not cause that, that
this stimuli need not cause that internal experience.
Over time, we would bring it closer and closer, in a
literal sense, that when you're in the presence of it,
when the therapist isn't in the room, or something,
that it won't automatically bring about an internal
experience as it has become when you're quote-
unquote "addicted". In a similar way, let's say it's
gambling, let's say every time you drive by the
casino or walk into a casino, you see the "object of
desire", so-to-speak, you fantasize about winning a
lot of money, your arousal goes up, you start getting
excited, and things like that--that's part of the
addiction, that's that "feeling" stuff that we were
talking about earlier. So what we would do in a
clinical session, is sort of, it would start with
probably just talking about slot machines in a
casino, and then ultimately we would be bringing in
pictures of a slot machine in a casino, but as we
noted, as a professional, that your arousal was
going up as your stimulation, where that "trigger"
was activated, we would go through a pre-
rehearsed relaxation technique, so we would start
to disassociate that high arousal with that trigger or
that stimulation. And over the course of many, many
sessions, we would eventually sort of even walk
with you into a casino, in-hand, and if you would
start to get aroused, we would ask you to go
through the relaxation thing, and eventually be able
to even touch a slot machine and not have that
automatic, addictive-like response.
What is "inpatient treatment" for behavioral
addiction?

Inpatient care in this country is a multi-billion dollar

business. There are a variety of different sort of
inpatient facilities, but they all are essentially the
same as they last around thirty days. Why thirty
days? Well, because the insurance companies
deem that an appropriate length of time. I'm not a
believer that it's a magic number; that thirty days is
the magic cure. A twelve-step disease model, a
treatment centre, would typically again last thirty
days. You'd go to groups all day long. There would
be some individual therapy. There would be twelve-
step groups, of course, in the evening, and a follow-
up that would be involved in the twelve-step
community. Emphasis would be on doing the twelve
steps; the twelve steps of Alcoholics Anonymous.
Now, there's probably only five or six inpatient
facilities in the whole United States that primarily
the cognitive behavioural model, but they too sort of
align with the thirty-day idea. They do, as well,
focus on groups and individual talk therapy. There'd
be more emphasis probably on relaxation
techniques, and things to help the individual
desensitise to the arousal one might get when in the
presence of a video monitor, or something like that.
However, in a traditional twelve-step or diseased
model facility, I don't mean to say that they're awful,
but generally speaking you're not going to get that
much more than you would get in a traditional self-
help group for substantially a lot less money.
What are the advantages of in patient treatment
for behavioral addiction?

Inpatient care, even though I'm not a strong

advocate of it, does have it's place. When an
individual has true loss of control over their
behavior, their quality of life has deteriorated to a
point where they really can't function independently,
inpatient care is what's called for. Again, the trouble
I have with inpatient care as well, is that what
happens the day you get out? Almost anybody can
be absent from their addiction of choice when
they're locked up in a facility or in a closet, but what
happens when they get out and do the real thing?
But, nonetheless, if the addiction has taken such a
toll on you where you have no, seemingly anyway,
control over your behavior and there is no safe zone
from yourself, it's sometimes helpful to put yourself
into a residential facility. But, you have to want to be
given sort of an opportunity to get distance from all
that, all those triggers out there, all that stimulation
that has before sort of caused certain acting out,
certain activities that are not in your best interest.
So, it does have it's place, but limited and ultimately
you must learn how to survive outside of that
environment or the obvious is you'll have to live in
seclusion.
What is the cost of inpatient treatment for
addiction?

Inpatient treatment varies accordingly to the state,

and the services provided; you can get inpatient
treatment at a very reasonable price, but the quality
is usually not so qualitative. Inpatient services are
very, very expensive in general. It ranges anywhere
from the very lowest that I've ever heard of is
something like $10,000 $15,000 dollars for thirty
days to a place in Malibu, or a couple of these
island retreats, where we're talking $70,000 to
$100,000 dollars a month. The quality of treatment
is not directly correlated with the cost, it has a lot to
do with who owns it and the motivation of the
owners, and "What kind of philosophy does the
treatment facility offer?"
What happens during a week at an inpatient
behavioral addiction facility?

A week at a twelve step facility is very, very, very

structured. When you walk into a twelve step
facility, non-twelve step facility you are going to be
handed a schedule and this schedule will be: eight
o'clock in the morning or seven o'clock in the
morning you wake up, seven thirty you make your
bed, eight o'clock you have breakfast, eight thirty
we have sort of a morning group, nine we have an
educational group, ten o'clock we have this type of
group or individual therapy, recreational therapy,
lunch, dinner. It's a very, very structured week.
There is very little room for little things other than
following and going to services that they designed
for you, that's one of the values of a inpatient facility
is cause many people with addiction can not
structure their day. In addition, it does set the stage
to some degree of momentum when they get out of
residential to have a basic structure how to
formulate a day that is healthy and promotive of life
enhancing activities.
What keeps patients from leaving inpatient
behavioral addiction therapy?

Nothing keeps patients from leaving inpatient

behavioural addiction therapy. As a patient you
need not worry if you go in and you decide you
really can't stand it or you really don't want it. You
do have the right in this country. I do understand
there are places outside of the U.S. where there are
laws stating you can incarcerate someone against
their will. But for a behavioural addiction patient in
the U.S. or really in most places, you can check out
if you don't like it. You need not feel that
claustrophobic feeling. I've worked with people with
behavioural addictions who are scared of a
residential because they feel like they're going to be
locked up and the key's going to be thrown away.
Their family wants them out of their life, and this is
just a stepping stone. But again, I can reassure you,
to the best of my knowledge, there are very few of
those types of inpatient facilities in the U.S. or
around the world for patients with behavioural
addiction.
What are the rules of a behavioral addiction
inpatient facility?

Yes, there's quite a few demands on anybody that

goes into any sort of residential inpatient facility. But
they mostly revolve around not obviously using
drugs, trying not to engage in their addictive
behavior, generally speaking they do not have
access to computers, cell phones, typical outside
sort of connection. The goal, again, is to cut the
individual away from the environment that fostered,
literally fostered, part of this addiction. So there's a
big disconnect, there's usually just one telephone
on the ward where everyone has to use it calling in,
calling out, and it's only allowed during certain
hours. And you're not supposed to isolate, you
know, not avoid groups and there's certain sort of
each--depending on the facility and their rules, it
gets more intense but those are sort of general
rules that you might find in an inpatient facility.
What happens for behavioral addicts after
inpatient care?

Outpatient, or after care, is probably one of the

more controversial domains right now in the
addiction field. It's come to be recognized that the
greatest failure of addiction treatment right now lies
in after care. Historically, people check-out after
thirty days, or maybe even sometimes forty-five
days, and they say, "Good-bye". then there's very
little follow-up. The hospital never calls them again
and they're just left to their own devices.
Unfortunately, that still continues on a very large
scale. There are some more progressive inpatient
facilities that do follow-up, provide after care
services, provide services via telephone, and
annual meetings where you come back to the
facility. Other places have developed contractual
relationships to outpatient services within various
communities around the country and you would be
assigned a counsellor at a facility local to you,
continuing with the same philosophy that you were
taught while you were inside the treatment facility.
What is "outpatient care" for behavioral
addiction?

Outpatient services are quite a bit broader than

inpatient services. If you're looking for a particular
orientation, be it more eastern, more cognitive
behavioral for that matter, the choices are much
broader than residential. The choices, therefore, lie
everything from one on one individual therapy to
group therapies that meet once a week, to support
groups such as Smart Recovery or Moderation
Management or, you know, the twelve step
approach. Or there are very formalized outpatient
programs, we go one, two, three hours a day, three,
four days a week for 3 to 6 months. So the range is
quite large and it is very helpful to stay involved.
These addictions are not cured with a shot or any
medication, they're cured through practice of doing
things, doing life another way.
What are the advantages of outpatient care for
behavioral addiction?

Outpatient services for behavioural addiction are

preferable primarily because you're living in the
environment that you're going to live in after all the
treatment is completed. With outpatient care, you're
going to be faced with the stresses of life that you're
going to have to live with later. You're going to have
to deal with your relatives or family or friends that
you're going to have to confront later. So outpatient
care, in my opinion, is the best. Beyond that, there's
the cost. There's the idea that you will be able to
stay at work and there is no shame and you don't
have to leave your job and tell everybody that
you're going away to some unknown destination for
3 days. It's convenient and it makes the recovery
clear. Outpatient care for behavioural addiction is
useful because you're going to talk about the
dilemma that you face today and that isn't going to
be that different from the dilemma you're going to
face six months from now. It's real. It's not an
artificial amount of stress or an artificial community
of people. It's your real life. Therefore I'm a big
advocate of outpatient resources.
What is the cost of outpatient treatment for
behavioral addiction?

Outpatient care ranges from free of charge,

meaning self-help groups like SMART Recovery,
Moderation Management, but there's also some
other ones like SOS, Women for Sobriety and
Recovery Incorporated. These are all out-patient,
free, self-help groups that are available via the
internet. Not every single town has one, but please
look at the internet, and you'll see if there's a
meeting by you. Each of the philosophies are
somewhat different, but they're free of charge. Now
the price goes up from there, of course. You know,
an individual therapist can range from, you know,
$75 an hour to $350 an hour. You could go once a
week, you could go twice a week, you could go
three times a week, 'cause that could be quite
expensive. Outpatient structured, outpatient is
generally somewhere between the $3,000 and
$5,000 range for three months.
What is outpatient treatment like for behavioral
addiction?

A typical week, if a behavioural addict were involved

in a structured outpatient program, would be very
structured and monotonous. Let's say you joined a
program three days a week, three days a week you
would be going to the facility, you'd be having a
group, maybe what's called a process group where
you just talk about feelings and your experiences,
followed by an educational group where there's a
new topic discussed, followed by a third activity,
and that would happen three times a week.
Traditionally, outpatient treatment centers for
behavioural addicts have one component, one night
a week, where you bring your family in, and the
family is involved in some part of your treatment.
They're often separated groups; you're generally
not in the same group as your family member.
Some people integrate them as well. But for the
course of three months, this what you're going to do
the same amount of hours the same night for three
months. Following that, or in addition to that, they
always recommend a support group to adjunct, to
fill in the spaces between the time the formal
educational treatment is provided to the behavioural
addict.
How can recovering behavioral addicts reduce
the risks in their environment?

Just knowing that there are risks out there. It isn't

only your behavioral addiction that you need to be
worried about. The behavioral addiction doesn't
happen without some sort of trigger, or stimulus,
especially in the cognitive behavioral sort of
conceptualization. So, knowing about them, and
learning to relate to these stimuli in a different way.
Let's say it's your spouse that makes you think
about going gambling or looking at pornography.
Part of your task, and part of the treatment, really is
learning how to, I'll call it dance with your spouse in
a different way, and I don't mean dance like the cha
cha cha. I mean dancing like how do you talk, how
do you communicate, how do you solve problems,
how do you not solve problems? How do you deal
with problems with the children? How to you deal
with problems of money? How do you deal with
problems of sex? All these things need to be
renegotiated and reworked for a couple. I'm using
this as the example, for you to minimize the
dangers that truly do exist in your outpatient or in
your real life environment.
What is the role of psychotherapy in outpatient
care for behavioral addiction?

The role of therapy in outpatient care, depending on

what professional you talk, to varies considerably
from disease oriented people, twelve steppers tend
to see psychotherapist as anti-therpeutic or anti AA.
That's always where that schism that tends to
happen. It's not a 100% of the time but generally
speaking psychotherapy is not endorsed from my
professional experience by 12 step community and
things like that. Their belief is that psychotherapy
pulls up to many anxieties and issues separate from
the addiction itself and it may be better to postpone
psychotherapy until 6 months, a year down the
road. Others types of treatment actively encourage
psychotherapy. Cognitive-behavioral programs
definitely encourage psychotherapy as ongoing,
working through the feelings, the thoughts, the
behaviors, relating to the triggers differently, relating
to the environment differently. When you pull an
addiction away from somebody your, it's like pulling
a blanket back and all of the sudden you notice all
of these feeling that were underneath the addiction
and that weren't seen by the individual or the world
and those are the topics often that are discussed in
psychotherapy.
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