Applied Behavior Analysis in Treating Alcohol and Drug Abuse

Applied behavior analysis (ABA) is used in drug and alcohol substance abuse programs to treat destructive addictions by applying the tenets of operant conditioning to reduce behaviors associated with drug-seeking and use. Frequently combined with cognitive therapies, ABA in addiction treatment has been shown to be an effective method of reducing dependency problems among addicts.

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Drug addiction is one of the most costly and disruptive public health issues facing the United States today. According to the National Institutes of Health, drug, alcohol, and tobacco use costs the country more than $500 billion in medical and related expenses each year, far and away the most expensive health-related problem in the country.

Although the exact causes of addiction remain obscure, it’s generally agreed now that it is rooted in a combination of genetic and environmental factors.

To applied behavior analysts, drug and alcohol abuse is simply another type of aberrant and damaging behavior that can be modified with the proper application of operant conditioning techniques.

Behavior Analysts Treat Addiction Issues as Trainable Behaviors

According to a 1979 report from the National Council on Drug Abuse, applied behavior therapies for addiction first took root in treatments for smoking and obesity rather than substance abuse treatment. Initial results were typically encouraging, but long-term effectiveness remained elusive.

However, as highly addictive drugs such as heroin, cocaine, and methamphetamines began to rise in popularity, behavioral treatments became one of the most effective tools to address the issue.

Contingency management (CM) is the most widely-used ABA technique in addiction treatment. A 2007 report detailing guidelines for psychosocial interventions and opioid detoxification published by the National Collaborating Centre for Mental Health in the United Kingdom suggest that CM is among the most effective treatment techniques for those addictions available today.

CM uses operant conditioning techniques to provide positive reinforcement as a reward for approved behaviors and negative reinforcement as a punishment for destructive or damaging behaviors, implementing the so-called ABCs of applied behavior analysis:

  • Antecedent – The prompt, or initial situation, leading to a behavior—feelings of depression, anxiety, worthlessness, or a desire to escape reality and experience positive feelings.
  • Behavior – The action or behavior in response to the antecedent—drinking, smoking, injecting heroin or taking other drugs.
  • Consequence – The reinforcement mechanism associated with the behavior—having the pleasure centers of the brain stimulated by the drug.

This cycle reinforces the addictive behavior and the responsibility of the ABA is to use CM and other behavior modification techniques to break it.

Voucher-Based Reinforcement Therapy (VBRT)

One of the most common CM methods, called voucher-based reinforcement therapy (VBRT), has proven particularly effective in substance abuse programs. A variation on the token economy, in which arbitrary tokens are offered in exchange for engaging in approved behaviors (or avoiding unapproved behaviors) and later exchanged for concrete rewards, VBRT has been used in cocaine and heroin treatment programs with a remarkable 95 percent success rate across 30 different studies. Participants receive tokens for turning in drug-free urine samples during the course of the program.

Another VBRT study demonstrated that very large reinforcers ($100 in vouchers for 48 hours of abstinence) achieved an 80 percent success rate in only two days.

Relapses Lead to New Therapeutic Techniques for Addiction

But like many treatment programs, effectiveness falls away dramatically when the treatment program concludes. Relapse rates for VBRT are comparable to non-ABA treatments… only 54 percent of the participants in the large reinforcer study maintained their abstinence into the following week, a rate consistent with the overall ratio of relapses for any type of drug-abuse treatment.

The problem of relapse is receiving considerable attention from behavior analysts, however. Some researchers believe that the answer may be found in a combination of behavior analysis and cognitive therapy techniques, an approach known as CBT (cognitive behavior therapy) that is already common in the treatment of mental health disorders.

CBT combines the operant conditioning techniques of applied behavior analysis with a psychological component of cognitive therapy.

As a method that combines the treatment of the observable behaviors of addiction with a mental model that attempts to correct the destructive, negative thoughts that frequently accompany them, CBT attacks the problem of addiction at both ends—the functional and the mental.

Practicing in Addiction Counseling as an Applied Behavior Analyst

ABAs working with substance abusers are usually employed by social services or dedicated inpatient addiction treatment centers. The positions are very different in terms of patients and responsibilities:

  • Community Service Agency ABA – Working with non-profit social services providers, ABAs at these agencies typically work with low-income and traditionally neglected populations. They may have limited contact with individual clients, but instead work to quickly triage cases by performing intake examinations. Patients often have multiple, overlapping medical and mental issues in addition to substance abuse.
  • Addiction Treatment Center ABA – Addiction treatment centers typically serve populations that are more socioeconomically stable. Patients are likely to have more external support systems, and addiction may be the exclusive focus of therapy. More one-on-one contact can be expected and more intensive and consistent therapies can be implemented.

ABAs working for private clinics might also have clients with addiction issues. Although most behavioral counseling practices work primarily with autistic patients, families sometimes seek addiction counseling and treatment from private behavior analyst practices.

In all cases, ABAs will work with other caregivers and healthcare providers in the course of providing treatment. They may provide instruction or guidance to families for continuing behavioral therapies at home since relapse is such a significant issue. Frequently, ABAs supervise the implementation of behavior management plans by assistant staff or counselors, who have the most direct contact with patients. The ABA will be responsible for reviewing charts and other data and modifying treatment plans as therapy progresses.

Preparing for a Career in Substance Abuse Treatment as an Applied Behavior Analyst

Because of the prevalence of community-based and social-services addiction treatment programs, it’s relatively easy to gain experience in substance abuse treatment as a volunteer or counselor without direct education in the techniques of applied behavior analysis. Volunteering is an excellent introduction to the addiction treatment industry before making a significant investment in training or education. Volunteer experience will also look good on resumes and graduate program applications.

Becoming a fully-fledged applied behavior analysis will require a master’s degree or higher, usually in either psychology or applied behavior analysis. It’s also possible to obtain an advanced degree in addictions counseling or alcohol and drug abuse studies and complement it with a graduate certificate in applied behavior analysis.

Any of these paths can get you started toward fulfilling the requirements for the Board Certified Behavior Analyst (BCBA®) certificate from the Behavior Analyst Certification Board (BACB). This certification is a requirement for many behavior analyst positions, and also frequently fulfills requirements for an ABA license in states that require licensing.

Counselors who are not fully-fledged ABAs, however, handle much of the direct supervision and patient interaction in the addiction treatment industry and often hold lesser credentials:

  • Board Certified Assistant Behavior Analyst (BCaBA®) – bachelor’s level credential that requires BCBA® oversight
  • Registered Behavior Technician (RBT®) – requires only a high school diploma, and is a strictly support staff role

Certified alcohol and drug counselors (CADC) are responsible for providing most addiction treatment services. There are many different certification options for substance abuse counselors, many of them offered at the state level. The National Association for Addiction Professionals and the National Board for Certified Counselors are two national certification programs, but you should check the state in which you plan to practice for specific requirements.

A degree in psychology or counseling is commonly required for counseling certifications. Applied behavior analysis courses are often available as a focus in psychology degree programs but may be difficult to find in counseling or addiction treatment degree programs.

Further Resources for Applied Behavior Analysts Working in Addiction Treatment

The Association for Addiction Professionals Certificate Programs – The NAADAC is a national non-profit offering three different levels of addiction treatment certification.

National Board for Certified Counselors – The NBCC offers a national counseling certification with a specialty option available for addiction counseling.

National Association for Addiction Treatment Professionals – A national non-profit association to provide leadership, advocacy, and training for addiction treatment providers.

American Addiction Treatment Association – An association of addiction treatment professionals that provides resources on regulations and best practice for the addiction treatment industry.

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