Simone Martin Oliani

Richard Alecsander Reichert

Roberto Alves Banaco Editors

Behavior
Analysis and
Substance
Dependence
Theory, Research and Intervention
Behavior Analysis and Substance Dependence
Simone Martin Oliani • Richard Alecsander
Reichert • Roberto Alves Banaco
Editors

Behavior Analysis
and Substance Dependence
Theory, Research and Intervention
Editors
Simone Martin Oliani Richard Alecsander Reichert
Centro Integrado de Neuropsiquiatria e Department of Psychobiology
Psicologia Comportamental (CINP) Universidade Federal de São Paulo
Londrina, PR, Brazil (UNIFESP)
São Paulo, SP, Brazil
Roberto Alves Banaco
Paradigma - Centro de Ciências e
Tecnologia do Comportamento
São Paulo, SP, Brazil

ISBN 978-3-030-75960-5    ISBN 978-3-030-75961-2 (eBook)

https://doi.org/10.1007/978-3-030-75961-2

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2021
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Foreword

The book Behavior Analysis and Substance Dependence: Theory, Research and
Intervention, organized by Simone Oliani, Richard Reichert and Roberto Banaco, is
another example of the breadth of the field explored by Behavior Analysis. I have
already written about this amplitude when talking about Aplysia, in one extreme,
and the analysis of the Brazilian Constitution, in the other.1 Focusing on the theme
of behavioral analysis of drug dependence, its effects and possibilities of interven-
tion by the psychologist, the chapters deal with diagnostic criteria, basic concepts of
behavioral pharmacology, functional analysis of the use and dependence on psycho-
active substances, establishing and abiding contingencies of the use of these sub-
stances, and various behavioral methods and techniques to address the problem; and
among the authors are the greatest Brazilian specialists in the study and treatment of
substance use disorders.

Association for Behavior Analysis International (ABAI),

Universidade de Brasília
João Claudio Todorov,
Brasília, Brazil
January 2021

1
Todorov, J. (2004). From Aplysia to the Constitution: Evolution of Concepts in Behavior Analysis.
Psicologia: Reflexão e Crítica, 17(2), 151–156. https://doi.org/10.1590/S0102-79722004000200003

v
Preface

There is a certain comfort in being a Darwinist. The belief in continuity between

species allows us to look elsewhere for the causes of problematic human behavior
rather than within ourselves. Many human behaviors seem to insist on going in the
opposite direction of survival and reproduction, in the saga of living in a hostile
environment, as if seeking to eliminate individuals so that they disappear in the
times to come. When we pursue the species’ hesitant steps in this direction, or even
against such fate, at first, we go after that which would be illogical for the species to
remain on the face of the Earth. And we call the behaviors found in this collision
course with human destruction itself as bizarre, inadequate, unsuitable or pathologi-
cal. We then proceed in search of what we supposedly know: solving problems of
Creation – be it attributed to a god, be it attributed to nature.
This is what happens with drug addiction. Although the beginning of its use may
have had some pleasant and reinforcing effects, the subsequent observation of the
harmful effects of its abuse should be enough for the other members to try to avoid
them. But it is not.
A refusal to the laws of Natural Selection was also created. Rather than, like in
other species, allowing it to act on the weakest and most maladaptive individuals,
sweeping them out of existence, we have followed a different path. We’ve tried to
avoid with all our strength that our peers say farewell to life, even when their own
behavior directs them towards it.
Perhaps we can find the explanation for the interference with other people’s lives
in the physically fragile origin of the human species in relation to other species (the
felines, for example), at the time when culture was beginning to develop. At that
time, living in a pack was good, because it was important for us to have behaviors
that could protect one another. The phylogenetic contingency prayed that the more
numerous we were within a group, the better it would be for everyone. And the
stronger we were, the better. Therefore, continuing our assumption, caring for each
other was a selected behavior in our species. Making a weak individual become
strong, a sick person getting healthy, started bringing benefits to everyone, making
the group and culture survive (Marcuse & Pear, 1979). Making the individual pro-
duce behaviors that left one strengthened and healthy also became a value towards

vii
viii Preface

the direction in which culture has walked. And perhaps medical therapies and later
psychological therapies started there. Therapies are nothing more than attempts to
make individuals who would be wiped out of existence by their behaviors stay here
a little longer.
One of the problematic behaviors that appeared, and that seemed to destroy the
existence of Humans was the adhesion of some individuals to the excessive use of
substances that altered the states of consciousness. In addition to putting the organ-
ism at risk, this behavior sometimes created problems for group living. And the
group is now more organized, trying to solve the problems caused by the individual
who was abusing drug use.
Many conceptions started to explain and to try solving the problem from that
explanation. They are described in Table 2.1 of Chap. 2, and I will not dwell on
them now. But the Darwinian conception, once again, was to look for traces of the
problem in phylogenesis. And it was found that so many other species also sought
to change their behavior when they consumed certain vegetables or their products.
For example, legend has it that coffee was discovered for human use in this way: an
Ethiopian shepherd who noticed that his sheep were excited when they ate the fruits
of the coffee tree. From that observation, many cultural practices have evolved,
making coffee today the second most consumed beverage in the world, second
only to tea.
But other species have been found that also seek to alter their states of balance
and behavior. Ronald Siegel (1979) mentions some of those: elephants look for
alcohol from fermented marula fruits or the drink already made from the fermenta-
tion of these fruits. For this reason, they illustrate the “Amarula”® liquor label. But
monkeys, ostriches, wildebeest, wild boar, giraffes and birds have already been reg-
istered that look for this fruit and have drunken effects.1 And they look for it again.
Cats – and other felines – are also fascinated by a hallucinogenic herb called Nepeta
cataria, which has, as an effect on their behavior, playing with “imaginary butter-
flies”. The “pet” market sells it under the name “catnip”, and it is possible to watch
on YouTube some videos about the hallucinogenic effects and the high caused by
the drug in animals.2 Pigeons and other birds, in turn, look for cannabis seeds and
experience behavioral changes. So much that they end up inadvertently identifying
and denouncing plantations.3 And, as it is in the public domain, koalas look for
eucalyptus that appears to have narcotic effects on them when consumed.4
The fact is that drugs end up becoming reinforcers acquired by their behavioral
and pharmacological effects (Garcia-Mijares & Silva, 2006) and some of them
interfere with responding processes, which in turn determine the operant behavior
of looking for the drug (Banaco & Montan, 2018). According to Cunningham
(1998), these responding processes are due to aversive sensations produced by the

1
An illustration can be seen in https://youtu.be/Aq9xx3hD-K0
2
https://youtu.be/cmkNtrno2Ek
3
https://www.youtube.com/watch?v=DN5HOMgZL-U
4
https://www.youtube.com/watch?v=DYFBsAG3VQs
Preface ix

opposite effect to that of the drug (which we usually call “craving”), elicited by the
antecedent stimuli conditioned to the drug use. For this reason, the drug is also con-
sidered an unconditioned stimulus, since its administration and its effects are also
controlled by the “cues” which precede them, turning these cues into conditioned
stimuli (Cunningham, 1998). Thus, the use of the drug would be negatively rein-
forced by the temporary relief experienced in the “craving” state in which the organ-
ism is when it comes in contact with the cues, which predict the relapse from time
to time, even after long periods without using the drug. Having contact with any
significant level of the stimulus conditioned to the use would already be enough for
the active search for the drug to begin, since in the past it has brought relief to the
discomfort caused by such stimulus.
Solutions to this problem which plagues society are sought, both by those who
try to “get people out” of substance dependence, and those who find themselves
“trapped” by it. In addition to several kinds of therapies already tried, several exper-
imental models, mostly with animals, seek to extract relevant variables to be manip-
ulated in the treatments. Hartnoll (1991), making a constructive criticism for this
search, without intending to discourage, points out some aspects that must be taken
into account in relation to the use of experimental models to search for solutions to
the problem.
The first one is that the classification of what would be considered a drug of
abuse is directly linked to the culture and the historical moment that is determining
the criterion from which the use will be considered abusive. For example, Hartnoll
points out that, from the legal point of view, at the time the author wrote the article,
the use and sale of marijuana, amphetamine, psychotropic drugs, cocaine and heroin
was considered illegal in the West, while in the East, especially in Arab countries,
alcohol use was very poorly evaluated. Today, in the West, marijuana has gradually
found a greater acceptance, both in recreational and medical use, given some of its
components. Nowadays, there is also a gradual increase in the acceptance of psy-
chotropic drugs, especially in psychotherapeutic processes.5 These types of sub-
stances, which were already widely used recreationally and religiously in the 60s
and 70s, have gone through a severe ban in the West in the 80s and onwards.
If the behavioral control agency is Health and General Medicine, then they con-
sider drugs of abuse to be those that are most likely to cause harmful consequences
to one’s health. In this case, the worst use will be considered by professionals, in the
following order of importance: tobacco, alcohol, tranquilizers, opiates and stimu-
lants. From the point of view of Epidemiology (frequency of use in the population),
by far the biggest drug of abuse is caffeine (found in coffee, teas, soft drinks). Then
alcohol, tobacco, marijuana, tranquilizers, and far behind, amphetamines, psycho-
tropics, cocaine and opiates. If the assessment is made by the criterion of self-­
administration, that is, drugs that produce a greater craving, the sequence, in order
of damage relevance is: cocaine and amphetamines, opiates, barbiturates,

5
https://icpr2020.net/tc-events/icpr-2020-online/
x Preface

dissociative anesthetics, alcohol, nicotine, caffeine and benzodiazepines, and finally,

with a low level of physical dependence, marijuana (Hartnoll, 1991).
As for drug abuse and self-administration, experimental models reveal that drugs
widely used by man are not self-administered in the laboratory (tobacco, marijuana,
caffeine) or are not easily self-administered (alcohol, benzodiazepines, psychotro-
pics). Other drugs that are easily self-administered in the laboratory in animals are
not widely used by men (especially opioids and some stimulants). To get an idea of​​
the difficulty in making an experimental model to study self-administration,
Elsmore, Fletcher, Conrad and Sodetz (1980) subjected baboons to choices between
food and heroin by attempts, increasing the cost of the choice response, simply by
gradually increasing the interval between attempts. The monkeys kept their number
of choices for food stable in each successive phase of increasing the cost of the
response, and decreased their choice of heroin, proportionally to the cost. The data
obtained were analyzed by Green and Freed (1998) representing, in Behavioral
Economics, as food being an inelastic asset (its high importance was maintained,
despite successive increases in the response cost), while heroin proved to be an
elastic asset (its choice decreased as the “price” to be paid increased). In humans,
we see some users who stop eating to use drugs. But it is far from the majority. Most
cocaine users, for example, are occasional and do not become addicted. Of those
who have become addicted, most return to moderate use. And it is known that users
who require treatment already suffered from other problems before cocaine addic-
tion (Cunningham, 1998).
When taken to the laboratory, cocaine has a high potential for abuse. Under con-
ditions of unlimited access to the drug, monkeys and rats can self-administer it until
they reach the point of having seizures and, in some cases, causing their death.
Cunningham recalls, however, that the animals used in the laboratory live in isola-
tion, kept in small cages. Self-administration takes place through an implanted cath-
eter, with few responses available in the experimental environment, other than to
press the bar to release the drug. Men in isolation (prisons, for example) can do the
same thing, if the drug is available, since functionally the environment for them is
very similar: cells with little space for good coexistence, few activities, and at the
same time with the drug being available. Self-administration studies in isolated ani-
mals, therefore, have a doubtful validity about how humans behave in their social
and natural environments.
In addition, it is known that rats and monkeys are social animals and, therefore,
to mimic the human problem in the laboratory, one should use social models with
availability of drug use, but these are difficult to craft. Perhaps this type of model
would bring relevant knowledge, at least, about the first times individuals use drugs.
In humans, usually, the first experiences with drugs are situations of social confor-
mity (teenagers starting to smoke, for example), some social rituals (drinking coffee
in pairs or groups in the morning), situations of reinforcement for “being part of the
group” (for example, the use of alcohol since one’s childhood, in a family that takes
Preface xi

pride in drinking a lot6). There are also cases in which people start using drugs in
search of a meaning for life (psychotropic to increase awareness: Santo Daime in
religious rituals, psilocybin and other psychedelic drugs in psychotherapies7).
Even with these difficulties in transposing animal models to humans and vice
versa, some ways of dealing with the problem end up being extracted from this lit-
erature. According to Cunningham (1998) there are several:
One is the effort to remove stimuli associated with the drug, or to remove the
individual from the environment associated with it. This is extremely difficult, but
there are strong indications that this removal is beneficial: of the total number of
substance dependent people who returned from the Vietnam war and went to a reha-
bilitation service, it was observed that 54% of those who went to new homes
remained abstinent, while only 12% remained abstinent when they returned to their
original homes. But, obviously, this change to new environments after detoxifica-
tion is practically impossible.
Another procedure extracted from these models is to make the respondent extinc-
tion by unpairing the stimuli that are triggers for craving responses from drug use.
The major difficulty lies in identifying which aspects of the environment the drug
was paired with.
A good clue that we can use is found in the Latent Inhibition literature. For
example, Lubow and Moore (1959) exposed sheep to a sun picture several times,
without any event following that exposure. This made “sun” a known stimulus, not
paired with anything. Then, they made a Pavlovian pairing between that same pic-
ture with light shocks released on the animal’s hind leg, which produced responsive
flexing, up to the point that the sun picture, now assuming the function of condi-
tioned stimulus after training, produced the leg flexing before the shock release.
They proceeded in the same way with a cloud picture, which was a new stimulus
for the sheep. The data showed that the cloud picture has acquired the property of
conditioned stimulus much earlier than the sun picture. This means that more com-
mon stimuli in one’s life take longer to have the property of producing the condi-
tioned response. One way, therefore, of being able to find the relevant stimuli for
relapses, would be to probe with the drug dependent individual which stimuli were
new when the substance use started. These stimuli are likely to elicit craving
responses.
One can also try the contextual control of extinction that is set by exposing the
individual to the complete context of pairing with drugs, obviously without allow-
ing its use. The limitation of this proposal is clearly “convincing” the context (espe-
cially the social one) to take part in it.
Another possibility is called “conditioned inhibition”, a procedure in which the
presentation of a stimulus that was previously paired with “non-drug” must inhibit
the conditioned response when presented with the drug-paired stimulus. The

6
“In my house everyone is groovy, everyone drinks, everyone dances” – Martinho da Vila (Brazilian
singer). https://www.youtube.com/watch?v=Wht3Ab8DJ6w
7
https://www.uol.com.br/ecoa/reportagens-especiais/terapias-psicodelicas-podem-virar-o-jogo-no-
tratamento-de-doencas-mentais/#page33
xii Preface

obstacle to this procedure is the same as above: finding out what is the conditioned
stimulus that produces craving responses.
The difficulties do not end there. There are also other respondent properties that
hinder the management of antecedent stimuli. Many of the CSs for CRs can be
interoceptive (e.g., mood states). When this is identified, it becomes much more dif-
ficult to program the extinction of the pairing, since the control of mood states
depends on events in the outside world. Sometimes due to aversive situations, which
would not be ethical or possible to be manipulated (for example, the depression
caused by the abandonment caused by a significant other). Another difficulty, disin-
hibition of the already extinct pairing can also occur when a new and intense stimu-
lus restores the conditioned response to a conditioned stimulus after the extinction
of the pairing has been completed (Cunningham, 1998).
In conclusion, the challenge is huge, relevant and important to be faced. More
and more humans are dependent on substances either to achieve well-being, or to
live the lifestyle which was promised in a capitalist system. It is not uncommon to
see people who are dependent on sleep inducers or anxiolytics in order to be able to
sleep. And a good percentage of those same people, need to take stimulating drugs
in order to be able to do their jobs or acquire a desired level of concentration the
next day. We are at a time when we are encouraged not to feel a minute of suffering.
And we are presented, as one of the possibilities of not feeling, the use of substances
that have the property of “erasing” such feelings, keeping us in the contingency that
produces them. In any case, it is necessary for behavior analysts who deal with sub-
stance dependence to take into account respondent processes with the same impor-
tance as they deal with operant processes and verbal operants. The control of nature
is still far from being achieved. Let us keep studying it in every possible way.
From the eighth month of reclusion during the COVID-19 pandemic

Londrina, Paraná, Brazil Roberto Alves Banaco

References

Banaco, R., & Montan, R. (2018). Teoria analítico-comportamental. In N. Zanelatto & R. Laranjeira
(Eds.), O tratamento da dependência química e as terapias cognitivo-comportamentais: um
guia para terapeutas (2nd ed., pp. 115–132). Artmed.
Cunningham, C.L. (1998) Drug Conditioning and drug-seeking behavior. In W. O´Donohue (Ed.)
Learning and behavior therapy (pp. 518–544). Allyn & Bacon.
Elsmore, T. F., Fletcher, G. V., Conrad, D. G. & Sodetz, F. J. (1980). Reduction of heroine intake
in baboons by an economic constraint. Pharmacology, Biochemistry & Behavior 38, 715–721.
https://doi.org/10.1016/0091-­3057(80)90018-­0
Garcia-Mijares, M., & Silva, M. T. A. (2006). Dependência de drogas. Psicologia USP, 17(4).
https://doi.org/10.1590/S0103-­65642006000400012
Green, L., & Freed, D.E. (1998). Behavioral Economics. In W. O´Donohue (Ed.) Learning and
behavior therapy (pp. 274–300). Allyn & Bacon.
Preface xiii

Hartnoll, R. (1991). The relevance of behavioural models of drug abuse and dependence liabilities
to the understanding of drug misuse in humans. In P. Willner (Ed.), Behavioural models in
psychopharmacology: theoretical, industrial and clinical perspectives (503–519). Cambridge
University Press.
Lubow, R. E., & Moore, A. U. (1959). Latent inhibition: The effect of nonreinforced pre-­exposure
to the conditional stimulus. Journal of Comparative and Physiological Psychology 52(4),
415–419. https://doi.org/10.1037/h0046700
Marcuse, F. L., & Pear, J. J. (1979). Ethics and animal experimentation: personal views.
In J.D. Keehn (Ed.), Psychopathology in animals: research and clinical implications
(pp. 305–329). Academic Press.
Siegel, R. K. (1979). Natural animal addictions: an ethological perspective. In J.D. Keehn (Ed.),
Psychopathology in animals: research and clinical implications (pp. 29–60). Academic Press.
Contents

Part I Introductory Aspects and Main Concepts

  1 Drug Abuse: Classifications, Effects and Risks������������������������������������    3
Richard Alecsander Reichert, Kallinca Merillen Silveira,
Fernanda Machado Lopes, and Denise De Micheli
  2 Behavioral Analysis of Substance Use and Dependence:
Theoretical-Conceptual Aspects and Possibilities for Intervention����   21
Richard Alecsander Reichert, Simone Martin Oliani,
and Roberto Alves Banaco
  3 Criteria for Substance Use Disorders Diagnosis (SUD):
An Behavioral-Analytic Perspective������������������������������������������������������   29
Fábio Henrique Baia, André Amaral Bravin,
Wilson Benício Martins, and Rogério Guaita dos Santos Baia
  4 Basic Concepts of Behavioral Pharmacology����������������������������������������   39
Fábio Leyser Gonçalves
  5 Functional Analysis of Substance Use and Dependence����������������������   51
Richard Alecsander Reichert, Eduardo José Legal,
Simone Martin Oliani, and Denis Roberto Zamignani
  6 Establishing and Abolishing Contingencies of Crack Use:
User Descriptions of a CAPSad��������������������������������������������������������������   61
Eduardo Coelho Abreu and Elizeu Borloti

Part II Clinical and Social Interventions

  7 Contingency Management for the Treatment of Substance
Use Disorders��������������������������������������������������������������������������������������������   77
Viviane Simões, Rodolfo Yamauchi, and André Q. C. Miguel

xv
xvi Contents

  8 Cue Exposure Therapy for Substance Use: A Complement

to Functional Analysis�����������������������������������������������������������������������������   89
Rodrigo Noia Mattos Montan and Roberto Alves Banaco
  9 Functional Analytic Psychotherapy (FAP) as an Adjunct
Treatment to Substance Dependence Cases������������������������������������������ 109
Alan Souza Aranha, Claudia Kami Bastos Oshiro,
and Elliot Cozzens Wallace
10 Dialectical Behavioral Therapy (DBT) for Substance
Use Associated with Borderline Personality Disorder�������������������������� 129
Jan Luiz Leonardi and Dan Josua
11 Contributions of Acceptance and Commitment Therapy (ACT)
with an Emphasis on Values and Committed Actions
in the Treatment of Substance Dependence������������������������������������������ 147
Rafael R. de Q. Balbi Neto and Simone Martin Oliani
12 Therapy by Contingencies of Reinforcement (TCR)
and Substance Dependence: A Clinical Case Presentation������������������ 163
Alan Souza Aranha, Luciana Pellizzaro Naine,
and Claudia Kami Bastos Oshiro
13 Motivational Interviewing Under a Behavior
Analysis Perspective�������������������������������������������������������������������������������� 193
César Silva Rodrigues Oliveira and Edson Massayuki Huziwara

Part III Special Topics

14 Interfaces Between Neurosciences and Behavior Analysis
on the Use of Psychoactive Substances�������������������������������������������������� 207
Myenne Mieko Ayres Tsutsumi, André Luiz, Carlos Eduardo Costa,
and Célio Roberto Estanislau
15 Behavioral Functions of Drug Use in Marital Narratives:
From Progression to Treatment of Substance Dependence������������������ 219
Jaqueline Vago Ferrari and Elizeu Borloti
16 Drugs Use in Romantic Relationship and Violence
Against Women���������������������������������������������������������������������������������������� 243
Vânia Lúcia Pestana Sant’Ana and Débora Barbosa de Deus
17 Challenges of Clinical Behavior Analysis in Legal Substance
Use: Alcohol and Tobacco������������������������������������������������������������������������ 257
Fernanda Calixto

Index������������������������������������������������������������������������������������������������������������������ 267
About the Contributors

Eduardo Coelho Abreu Master in Social Psychology from the Post-Graduate

Program in Psychology of the Federal University of Espírito Santo (UFES) and
graduated in Psychology from the Faculdade Brasileira.

Alan Souza Aranha PhD student in the Department of Clinical Psychology of the
University of São Paulo (USP). Specialist in Behavioral Therapy from the Institute
of Therapy by Contingencies of Reinforcement (ITCR-Campinas).

Fábio Henrique Baia Master and Doctor in Behavioral Sciences from the
Universidade de Brasília (UnB); and Bachelor in Psychology from the Pontifícia
Universidade Católica de Minas Gerais (PUC-Minas). He is currently a Full
Professor at the School of Psychology of the Universidade de Rio Verdade (UniRV)
and a post-doctoral fellow in Experimental Psychology at the Universidade de São
Paulo (USP).

Roberto Alves Banaco Master and PhD in Experimental Psychology from the
Universidade de São Paulo (USP); and graduated in Psychology from the Pontifícia
Universidade Católica de São Paulo (PUC-SP). He is academic director and profes-
sor of the Paradigma – Centro de Ciências e Tecnologia do Comportamento (Center
for Behavior Sciences and Technology); Member of the Brazilian Society of
Psychology (Sociedade Brasileira de Psicologia – SBP); Member of the Board of
the Brazilian Association of Psychology and Behavior Medicine (Associação
Brasileira de Psicologia e Medicina Comportamental – ABPMC); and Behavior
Analyst accredited by the ABPMC. He has experience in Psychology, with empha-
sis on Psychological Treatment and Prevention, acting mainly in the following
themes: behavior analysis, experimental behavior analysis, behavior analytic ther-
apy, radical behaviorism and applied behavior analysis.

Elizeu Borloti PhD in Psychology from the Pontifical Catholic University of São
Paulo (PUC-SP); Master in Psychology from the Federal University of Espírito
Santo (UFES); and Specialist in Chemical Dependency from UFES. He is a

xvii
xviii About the Contributors

Behavioral Therapist, professor and researcher of the Post-Graduation Program in

Psychology at UFES. He has experience in Psychology, with emphasis on
Experimental Behavior Analysis and Psychological Prevention and Treatment, act-
ing mainly on the following themes: verbal behavior, psychological disorders,
stress, culture behavioral analysis, behavior and health and substance dependence.

André Amaral Bravin Master and Doctor in Behavior Sciences from the
Universidade de Brasília (UnB); Expert in Clinical Psychology (Clinical Behavioral
Analysis) from the Brasiliense Behavior Analysis Institute (Instituto Brasiliense de
Análise do Comportamento – IBAC); and Bachelor in Psychology from the
Universidade Católica de Brasília (UCB). He is currently a Full Professor at the
School of Psychology of the Universidade Federal de Jataí (UFJ).

Fernanda Calixto She holds a Ph.D. in Psychology, and a post-doctoral degree

from the Federal University of São Carlos (UFSCAR) and the Paradigm Center for
Behavioral Sciences and Technology; a Master’s degree in Behavioral Analysis
from the State University of Londrina (UEL); and a degree in Psychology from the
Federal University of Mato Grosso do Sul (UFMS). She develops research, inter-
ventions, and supervision related to the following themes: self-control, impulsive-
ness, gaming and internet addiction, aggressiveness, compulsion, substance
dependence, decision making, and personality disorders.

Carlos Eduardo Costa Graduated in Psychology at the Universidade Estadual de

Londrina (UEL); Master and PhD in Experimental Psychology at the Universidade
de São Paulo (USP). He did a post-doctoral internship with the Programa de
Mestrado Profissional em Análise do Comportamento Aplicada no Paradigma: cen-
tro de ciências e tecnologia do comportamento (Professional Master’s Program in
Applied Behavior Analysis at Paradigma – Behavioral Sciences and Technology
Center. He is an Associate Professor at the Universidade Estadual de Londrina
(UEL); Permanent Professor of the Programa de Pós-Graduação em Análise do
Comportamento – UEL (Graduate Program in Behavior Analysis at UEL); General
Editor of the journal Acta Comportamentalia and Associate Editor of the periodicals
Revista Brasileira de Análise do Comportamento (REBAC) and Perspectivas em
Análise do Comportamento; Member of REDETAC (www.redetac.org).

Débora Barbosa de Deus Master in Psychology from Universidade Estadual de

Maringá (UEM); Specialist in Behavioral Psychotherapy from UEM; Specialist in
Psychological Evaluation from Centro Universitário Integrado de Campo Mourão
(INTEGRADO); and graduated in Psychology from UEM.

Célio Roberto Estanislau holds a degree in Psychology and a Masters in

Neurosciences from the Universidade Federal de Santa Catarina (UFSC) and a PhD
in Psychobiology from the Universidade de São Paulo (USP). He did postdoctoral
studies at the Universitat Autònoma de Barcelona. He is a Professor at the
About the Contributors xix

Universidade Estadual de Londrina (UEL). He has experience in Psychology, with

emphasis on Psychobiology and Behavioral Neuroscience.

Jaqueline R. de Q. Vago Ferrari Master and PhD student in Psychology from the
Universidade Federal do Espírito Santo (UFES); Specialist in Epidemiology from
the UFES; Specialist in Cognitive-Behavioral Therapy from the Centro Universitário
Amparense (UNIFIA); and graduated in Psychology from the UFES. She has expe-
rience in Psychology with emphasis on Mental Health, Substance Dependency and
Clinical Psychology, working mainly with the following themes: welcoming and
humanization in the treatment of substance dependence, love relationship in sub-
stance dependence and prevention of substance use for children and adolescents.

Fábio Leyser Gonçalves Is graduated in Psychology and got a Master’s and

Ph.D. in Neuroscience and Behavior at the University of São Paulo (USP), where
he also served as post-doc. Currently, he is Professor in the Department of
Psychology of the School of Sciences at São Paulo State University (UNESP) and
on the Graduate Program in Neuroscience and Behavior of the Institute of
Psychology – USP. He has experience in Psychology and Behavior Analysis, with
emphasis in Electric and Drug Stimulation, acting mainly in the following themes:
impulsivity, delay discounting, depression, drug abuse and sensitivity to
reinforcement.

Edson Massayuki Huziwara PhD in Experimental Psychology from the

Universidade de São Paulo (USP); Master in Special Education and graduated in
Psychology from the Universidade Federal de São Carlos (UFSCar). He is an
Adjunct Professor of the Department of Psychology and of the Post-Graduate
Program in Psychology: Cognition and Behavior at the Universidade Federal de
Minas Gerais (UFMG). He has experience in Psychology, with emphasis on
Experimental Psychology, acting mainly in the following themes: stimulus equiva-
lence, stimulus control and conditional discrimination with human participants and
non-human subjects.

Dan Josua holds a bachelor’s degree in Psychology from PUC-SP, specialization

in Cognitive-Behavior Therapy from USP, training in Dialectical Behavioral
Therapy by Behavioral Tech, and a master’s degree in Clinical Psychology from
PUC-SP. He is currently the coordinator of Evidence-Based Psychotherapy Training
at InPBE – Institute for Evidence-Based Psychology, in addition to acting as a clini-
cal psychologist.

Eduardo José Legal Master and PhD in Experimental Psychology from the
Universidade de São Paulo (USP); and Bachelor in Psychology from the
Universidade Federal de Santa Catarina (UFSC). He is currently a professor in
undergraduate and master’s courses in Psychology at the Universidade do Vale do
Itajaí (UNIVALI). His research addresses the topics: neuropsychology of executive
functions, resilience and well being.
xx About the Contributors

Jan Luiz Leonardi holds a bachelor’s degree in Psychology from PUC-SP, spe-
cialization in Behavioral Therapy from Paradigma, training in Dialectical Behavioral
Therapy by Behavioral Tech, a master’s degree in Experimental Psychology:
Behavior Analysis from PUC-SP, and a PhD in Clinical Psychology from
Universidade de São Paulo (USP). He was the academic coordinator of Paradigma’s
advanced qualification program in Behavioral Therapy between 2014 and 2020 and
vice-president of the Brazilian Association for Behavioral Psychology and Medicine
(ABPMC) in the 2015-2016 term. He is currently the coordinator of Evidence-­
Based Psychotherapy Training at InPBE – Institute for Evidence-Based Psychology
and professor at Paradigma, in addition to acting as a clinical psychologist.

Fernanda Machado Lopes Psychologist, Specialist in Psychotherapy of Integrated

Techniques and Certified Therapist by the Federação Brasileira de Terapias
Cognitivas (Brazilian Federation of Cognitive Therapies). Master and PhD in
Developmental Psychology from the Universidade Federal do Rio Grande do Sul
(UFRGS), linked to the Laboratory of Experimental Psychology, Neuroscience and
Behavior (LPNeC-UFRGS) and Post-Doctorate in Neuroscience, linked to the
Laboratory of Psychobiology and Neurocomputation (LPBNC-UFRGS).
Experience as an Organizational Psychologist with an emphasis on Human
Resources Management and Traffic Psychology; as a Clinical Psychologist with an
emphasis on Cognitive-Behavioral Therapy and as a Teacher. Currently works as an
Adjunct Professor in the Department of Psychology at the Universidade Federal de
Santa Catarina (UFSC) and coordinates the Laboratory of Basic and Applied
Cognitive Psychology (LPCOG). Research Areas of Interest: Cognitive and
Neuropsychological Processes, Cognitive-behavioral Therapy, Drugs, Depression
and Anxiety.

André Luiz PhD student in Behavior Analysis at Universidade Estadual de

Londrina (UEL); Master in Behavior Analysis at UEL; Graduated in Psychology at
Universidade Positivo (Curitiba). He is an Adjunct Professor at Universidade
Positivo (Londrina) and Behavior Analyst at Núcleo Evoluir (Londrina). He devel-
ops research on behavioral resistance to change and response-cost.

Wilson Benício Martins Bachelor in Psychology at the Universidade de Rio Verde

(UniRV).

Denise De Micheli Graduated in Psychology from Universidade Paulista (UNIP),

with a PhD in Psychobiology and a Post-Doctorate in Science from Universidade
Federal de São Paulo (UNIFESP). Associate Professor of Medicine and Sociology
of Drug Abuse (DIMESAD) at the Department of Psychobiology of
UNIFESP. Coordinator of the Interdisciplinary Center for Studies in Neuroscience
and Behavior in Childhood and Adolescence (CIENCIA-UNIFESP). Member of
the Association for Medical Education and Research in Substance Abuse (AMERSA)
and the Brazilian Multidisciplinary Association of Drug Studies (Associação
Brasileira Multidisciplinar de Estudos sobre Drogas – ABRAMD).
About the Contributors xxi

André Q. C. Miguel Obtained his Doctoral degree at the Department of Psychiatry

of the Universidade Federal de São Paulo (UNIFESP); completed his Master in
Pathological Dependencies at the University of Pisa (Italy); and graduated in
Psychology by the Pontifícia Universidade Católica de São Paulo (PUC-SP). He has
a Post-Doctorate from the Department of Psychiatry of Yale University and the
Department of Psychiatry of UNIFESP and is currently an Assistant Professor at the
Elson S. Floyd College of Medicine at Washington State University.

Rodrigo Noia Mattos Montan Master Student in Applied Behavior Analysis at

the Associação Paradigma – Centro de Ciências e Tecnologia do Comportamento
(in english Paradigma Association – Center for Sciences and Technology of
Behavior); Specialist in Chemical Dependency at the Medical School of Universidade
de São Paulo (FMUSP); and a graduate in Psychology from Universidade
Presbiteriana Mackenzie. He was a member of the Interdisciplinary Group for the
Study of Alcohol and Drugs of the Institute of Psychiatry of the Clinical Hospital of
the Universidade de São Paulo (GREA - IPq/HC-FMUSP), and worked in Centers
of Psychosocial Attention Alcohol and other Drugs (CAPS ad). He develops studies
with cue exposure therapy and virtual reality for crack users. He volunteers as a
Clinical Supervisor at CAPS for cases of drug abuse among teenagers. Coordinator
and teacher of the Extension Course in Intervention in Cases of Chemical and
Behavioral Dependence at the Associação Paradigma – Centro de Ciências e
Tecnologia do Comportamento.

Luciana Pellizzaro Naine Specialist in Behavioral Therapy from the Institute of

Contingencies of Reinforcement (ITCR-Campinas). Clinical Psychologist in pri-
vate practice and supervisor of the Behavioral Therapy Specialization course at
ITCR-Campinas.

Rafael R. de Q. Balbi Neto Master and PhD in Psychology from the Universidade
Federal do Espírito Santo (UFES); and graduated in Psychology from UFES. He
has experience in the area of Clinical Psychology, with emphasis on Psychological
Assessment, Psychotherapy, Severe Mental Disorder and Substance Dependence.
He works mainly in the following themes: Behavior Analysis, Behavior Therapy,
Cognitive-­Behavior Therapy and Substance Dependence.

Simone Martin Oliani Graduation in Psychology from Centro de Estudos

Superiores de Londrina (CESULON). Specialization in Psychotherapy in Behavior
Analysis and Master in Behavior Analysis from the Universidade Estadual de
Londrina (UEL). Affiliate of ABPMC (Brazilian Association of Medicine and
Behavioral Psychology), regional coordinator of the ABPMC Community project.
She is also affiliated to ABEAD (Brazilian Association for the Study of Alcohol and
Other Drugs) and ACBS (Association for Contextual Behavioral Science).
Experience in Psychology, with an emphasis on Clinical Psychology, acting mainly
on the following themes: behavior analysis, substance dependence, prevention /
intervention and health psychology.
xxii About the Contributors

César Silva Rodrigues Oliveira Master in Development Neuropsychology from

the Universidade Federal Minas Gerais (UFMG); Specialist in Substance
Dependence from the Universidade Federal de São Paulo (UNIFESP); and gradu-
ated in Psychology from UFMG. He has experience in the Psychology area, with
emphasis on Behavior Analysis, acting mainly in the following themes: clinical
psychology, behavior analysis, psychiatric disorders, substance dependence and
group therapy.

Claudia Kami Bastos Oshiro PhD from the Department of Clinical Psychology
of the University of São Paulo (USP); Bachelor and Master in Special Education
from the Federal University of São Carlos (UFSCar). Specialist in Behavioral and
Cognitive Therapy from USP. Professor in the Department of Clinical Psychology
of USP.

Richard Alecsander Reichert PhD student in Psychobiology at the Universidade

Federal de São Paulo (UNIFESP); Researcher in the area of Medicine and Sociology
of Drug Abuse; Bachelors in Psychology at the Universidade do Vale do Itajaí
(UNIVALI); Member of the Interdisciplinary Center for Studies in Neuroscience
and Behavior in Childhood and Adolescence (CIENCIA-UNIFESP); Collaborator
of the Laboratory of Basic and Applied Cognitive Psychology (LPCOG) of the
Universidade Federal de Santa Catarina (UFSC); and associate member of the
Brazilian Multidisciplinary Association of Studies on Drugs (Associação Brasileira
Multidisciplinar de Estudos sobre Drogas – ABRAMD), International Society of
Substance Use Professionals, Brazilian Society for Neuroscience and Behavior
(Sociedade Brasileira de Neurociências e Comportamento, SBNeC), Brazilian
Network for Science and Education on Alcohol and other Drugs (Rede Brasileira de
Ciência e Educação sobre Álcool e outras Drogas), and International Network on
Brief Interventions for Alcohol & Other Drugs (INEBRIA).

Vânia Lúcia Pestana Sant’Ana PhD in Clinical Psychology from the Universidade
de São Paulo (USP); Master in Psychology from the Pontíficia Universidade
Católica de São Paulo (PUC-SP); Specialist in Psychology from the Centro de
Estudos Superiores de Londrina (CESULON); and graduated in Psychology from
the Universidade do Sagrado Coração (USC). She has experience in Psychology,
with emphasis on Sexuality and Learning, acting mainly in the following themes:
treatment, prevention, psychological intervention, radical behaviorism and human
sexuality.

Rogério Guaita dos Santos Baia Bachelor in Nursing from the Universidade de
Rio Verde (UniRV). He is a member of the Behavioral Analysis Research Group and
acts as a researcher in the Behavioral Medicine area.

Kallinca Merillen Silveira Graduated in Psychology at the Universidade Federal

de Santa Catarina (UFSC). Research Areas of Interest: Cognitive-behavioral
Therapy and Drugs.
About the Contributors xxiii

Viviane Simões Has a Master’s degree in Substance Use Disorder obtained at the
Universidade Federal de São Paulo (UNIFESP); Graduated in Nursing and in
Psychology at in Universidade Nove de Julho (UNINOVE).

Myenne Mieko Ayres Tsutsumi PhD student in Behavior Analysis at Universidade

Estadual de Londrina (UEL); Master in Neurosciences and Behavior at Universidade
Federal do Pará (UFPA); Specialist in Neurosciences at the UEL; and Bachelor in
Psychology at the UFPA. She is an Assistent Professor at Pontifícia Universidade
Católica do Paraná (Londrina) and an Adjunct Professor at Universidade Positivo
(Londrina). She develops research on aversive control and Autistic Spectrum
Disorder.

Elliot Cozzens Wallace Research Coordinator in the Department of Psychology

and The Department of Psychiatry and Behavioral Sciences at the University of
Washington. Bachelor’s of Science in Psychology from the University of
Washington. Bachelor’s of Arts in Spanish Literature and Language from the
University of Washington.

Rodolfo Yamauchi Has a Master’s degree in Substance Use Disorder obtained at

the Universidade Federal de São Paulo (UNIFESP) and in Neuropsychology from
the Conselho Federal de Psicologia (CFP); and graduated in Psychology at the
Universidade Metodista de São Paulo (UMESP).

Denis Roberto Zamignani PhD in Clinical Psychology from the Universidade de

São Paulo (USP); and Master in Experimental Psychology: Behavior Analysis from
the Pontifícia Universidade Católica de São Paulo (PUC-SP). Behavior Analyst
accredited by the Brazilian Association of Psychology and Behavioral Medicine
(Associação Brasileira de Psicologia e Medicina Comportamental – ABPMC);
Academic Coordinator and Professor of Paradigma – Centro de Ciências e
Tecnologia do Comportamento; Member of the Editorial Board of Perspectives on
Behavior Analysis and the Brazilian Journal of Behavioral and Cognitive Therapy,
published by ABPMC; Member of the Brazilian Society of Psychology and Society
for Psychotherapy Research. Coordinator of the Process-Based Studies Laboratory
in Analytical-Behavioral Therapy (TACn1) at the Paradigma – Centro de Ciências e
Tecnologia do Comportamento. He has experience in the Psychology area, with
emphasis on therapeutic intervention, psychotherapy research and professional
training for psychologists.
 Part I
Introductory Aspects and Main Concepts
Chapter 1
Drug Abuse: Classifications, Effects
and Risks

Richard Alecsander Reichert, Kallinca Merillen Silveira,

Fernanda Machado Lopes, and Denise De Micheli

Introduction

Drugs use is an ancient habit in human history. Over time, different substances have
been used in order to obtain pleasurable sensations, to mitigate or to eliminate aver-
sive feelings and to comply with several social, religious, and cultural purposes.
Psychoactive drugs, due to their action in the central nervous system (CNS), are
capable of generating modifications in the functioning of the organism, be it in
behaviors, in consciousness, in perceptions, or in emotion. Psychoactive drugs, in
addition to these modifications, usually, can also cause dependence. From a neuro-
psychological perspective, the continuous drug use behavior can be understood as a
learning process, in which the substance use is sustained due to the production of a
positive or negative reinforcing effect to the user. The issue of sustained use and
abuse of drugs is a complex one, and is related to biological, psychological, and

This text is an adapted translation of a chapter entitled: “Do consumo de álcool às drogas sinté-
ticas: efeitos e riscos do uso abusivo”, which is part of the book “Drogas, ciências e políticas
públicas: discussões interdisciplinares e práticas de saúde”, organized by Zaluar and colleagues
(2019) and published in Brazil.

R. A. Reichert () · D. De Micheli

Department of Psychobiology, Universidade Federal de São Paulo (UNIFESP),
São Paulo, SP, Brazil
e-mail: [email protected]
K. M. Silveira
Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
F. M. Lopes
Department of Psychology, Universidade Federal de Santa Catarina (UFSC), Florianópolis,
SC, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 3

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_1
4 R. A. Reichert et al.

Table 1.1 Classification of psychoactive substances

Depressants Stimulants Hallucinogens
They reduce or inhibit the They accelerate the activity They alter the functioning of the CNS
activity of the CNS of the CNS (amphetamines, in a qualitative and quantitative way,
(alcohol, solvents, cocaine, nicotine, caffeine, and may cause hallucinations and
inhalants, anxiolytics, among others). delirium (marijuana, ecstasy, LSD,
among others). among others).

sociocultural factors (Bedendo et al., 2017; Cho et al., 2019; Masur & Carlini, 2004;
Uhl et al., 2019) (Table 1.1).
The associated risks of the use of each of these substances are related to their
indiscriminate or abusive use (i.e. in inappropriate contexts and at inappropriate
times, when there is a higher probability of harm to yourself or others; in a high
frequency; or in a high quantity). Under the effect of psychoactive substances, sev-
eral negative consequences can occur, such as traffic accidents, unprotected sexual
activity (and, consequently, sexually transmitted diseases or unplanned pregnancy),
involvement in violent situations, difficulties in academic and professional life,
among others (De Micheli et al., 2015; UNODC, 2019; Whitesell et al., 2013;
WHO, 2009). In addition to these possible risks to the general population, the World
Health Organization (WHO, 2018), in one of the topics of its report on global alco-
hol use, discusses substance use specifically in adolescents; and warns of impacts
on the brain and neurocognitive development of adolescents, such as changes in
learning processes, memory, and attention, which can lead to physical and emo-
tional health problems in adult life. Moreover, it is important to highlight the pos-
sible social harm to the lives of adolescents who use substances, such as harm to
their social, family, and other interpersonal relationships.

Epidemiological Data

In Brazil, drug consumption has been increasing in the last 20 years and it has also
been associated with the occurrence of several social problems such as violence,
accidents, and diseases that can lead to death (Carlini et al., 2010). Data has also
been showing that drug abuse has been associated with the occurrence of serious
disorders that affect all areas of a person’s life, harming the individual’s integral
health (Oliveira & Argimon, 2015; Rangé & Marlatt, 2008). In addition, the fact that
the age group of drug consumption is becoming increasingly younger is also a mat-
ter of concern, especially because the earlier the use, the greater the chances of
developing patterns of drug dependency. All these elements make the abuse of psy-
chotropic substances a major public health issue.
Epidemiological data from the VI National Survey on Drug Use among Brazilian
Elementary and High School Students (Carlini et al., 2010) showed that drug exper-
imentation between youngsters in Brazil usually begins with licit drugs, about
13 years old for alcohol (predominantly in the family environment) and tobacco.
Later, between 14 and 15 years old, tends to occur the experimentation of illicit
1 Drug Abuse: Classifications, Effects and Risks 5

drugs, such as marijuana (about 14.6 years) and cocaine/crack (about 14.9 and
14.8 years, respectively).
Regarding last year’s consumption, licit drugs were the most cited (alcohol,
42.4%; tobacco, 9.6%), followed by inhalants (5.2%), marijuana (3.7%), anxiolyt-
ics (2.6%), cocaine (1.8%), and amphetamines (1.7%) (Carlini et al., 2010). In rela-
tion to the general population, the II National Alcohol and Drug Survey (LENAD)
showed a higher prevalence of licit drug use by adults. In 2012, 50% of those par-
ticipants consumed alcohol and 16.9% tobacco. Considering personal drug use, the
most cited drugs by adults were marijuana (6.8%), stimulants (2.7%), cocaine
(3.8%), and solvents (2.2%) (Laranjeira et al., 2014). According to the II Home
Survey on Psychotropic Drug Use in Brazil conducted in 2005 (Carlini et al., 2006),
12.3% of the Brazilian population was classified as alcohol dependent, a degree of
alcohol dependence higher than the world’s average, which ranges from 10% to
12% (Sordi et al., 2012).
Worldwide, the United Nations Office on Drugs and Crime (UNODC) estimates
that approximately 35 million people suffer from substance use disorders (SUD),
with only one to seven having access to treatment. International reports show an
increase in the number of individuals with SUD and give special attention to the use
of licit substances (such as alcohol and tobacco) and their adverse effects on the
health of the population. They also discuss the opioid crisis in North America,1
which is associated with an increase in the number of prescriptions and misuse of
these substances, and with an increased number of related deaths (UNODC, 2019,
2020; WHO, 2009, 2018).
WHO epidemiological data showed that approximately 2.3 billion people world-
wide consumed alcohol—recorded mainly in the form of distillates, beer, and
wine—in 2016, with per capita consumption equivalent to about 6.4 l of pure alco-
hol. In the Americas, Europe, and the Western Pacific, alcohol was consumed by
more than half the population. In this report, a decrease in the pattern of heavy
episodic drinking (binge drinking)—consumption of 60 g or more of pure alcohol
on one occasion at least once a month—was observed in the total population, given
that in 2000 the prevalence was 22.6%, while in 2016 it was 18.2%. However, there
were exceptions to some regions, such as Eastern Europe and Sub-Saharan Africa,
where the prevalence was higher. This report also presented information on alcohol-­
related diseases and injuries, exposing that alcohol consumption was associated
with 7.2% premature deaths, mainly of young people, between 20 and 39 years old.
In addition, alcohol consumption was also associated to millions of deaths from

1
The opioids were not addressed in the original text in Portuguese, because statistical-epidemio-
logical data showed that its use is not so common in Brazil compared to other countries. These
substances act mainly on the CNS by activating the mesolimbic reward system and sending signals
to the ventral tegmental area (VTA), releasing dopamine (DA) in the nucleus accumbens (NAc).
The main effects of this action are euphoria and analgesia. To better understand the neurobiologi-
cal mechanisms of action of opioids and their possible health risks, we suggest reading Evans and
Cahill (2016), Kakko et al. (2019), Koob (2020), Kosten and George (2002), and Napier and
Persons (2019). To see more on the opioid crisis in North America, we suggest reading Bolliger
and Stevens (2019), Boté (2019), and Stoicea et al. (2019).
6 R. A. Reichert et al.

digestive and cardiovascular diseases, cancer, traffic injuries, interpersonal vio-

lence, among others, in different ages (WHO, 2018).
Reports published in 2019, and 2020, by the United Nations Office on Drugs and
Crime (UNODC) showed that there was an increase in drug use by the world popu-
lation. In 2018, among the illicit substances, cannabis was the most used drug
(192 million people), while opioids were related to greater health damage (UNODC,
2019, 2020). In 2017, the opioids were associated with 66% of the 167,000 deaths
related to substance use disorders, in addition to millions of premature deaths and
disability-adjusted life years (DALYs). As for cocaine use, it is estimated that
18.1 million people consumed it in 2017, and that the highest prevalence of its con-
sumption was in North America (2.1%) and Oceania (1.6%) (UNODC, 2019, 2020).
Regarding other drugs, many countries, especially in Western Europe, have shown
concern with the use of over-the-counter tranquillizers. Its use has been more fre-
quent among women and, in some countries, more prevalent than cannabis. In coun-
tries of Asia, especially Southeast Asia, there is a great concern with the use of
methamphetamines, since according to those reports, the use of these substances
varies between 0.5% and 1.1%, higher prevalence than global rates (UNODC, 2019).
Given the impacts of the COVID-19 pandemic (such as increased levels of unem-
ployment and poverty and lack of opportunities), more attention is being paid to
drug-related problems (such as harmful use patterns and dependence), due to its
increased occurrence likelihood, around the world. That makes the formulation of
prevention and treatment strategies accessible to the entire population even more
important and urgent, taking into account the new context in which people are living
and its several social and economic transformations (UNODC, 2020).
In adolescence, specifically, health organizations pay attention to the greater vul-
nerability to physical, psychological, and social harm resulting from early drug use,
since adolescence is a phase of maturation of brain structures and functions and of
cognitive, emotional, and social development. That stated, the importance of target-
ing attention to psychoactive substance use patterns and the need to develop and
implement effective strategies to the prevention and treatment of drug abuse and,
consequently, to mitigate its potential negative and harmful effects in all population
is signaled. (Andrade et al., 2014; UNODC, 2019, 2020; WHO, 2009, 2018).

Consumption Patterns and Risk Factors

In relation to consumption patterns, it is necessary to reflect on the risk factors asso-

ciated with the early and abusive use of licit and illicit drugs. In the family context,
when there is a positive attitude of parents towards drug use, this influences the
early use by their children. Therefore, it is important to identify how the relation-
ships between users, types of drugs, and the permissive intrafamilial relationship
system are established (Paiva & Ronzani, 2009; Schenker & Minayo, 2005). In
addition to that, the role of group involvement, the search for risky situations, and
the media’s actions that encourage and praise the use of substances such as alcohol
1 Drug Abuse: Classifications, Effects and Risks 7

(Cambron et al., 2018; Oliveira & Argimon, 2015; Schenker & Minayo, 2005)
should also be taken into consideration when examining risk factors involved in
drug use.
Factors such as incentive and permissiveness of family to drug use; stressful situ-
ations, such as family crisis; incentive and permissiveness of groups, in which the
person interacts, to drug use; willingness to belong to certain groups that use drugs
or have it as a symbol of status; and curiosity to experiment are also all well-known
risk factors that collaborate for children and adolescents to start using drugs. The
UNODC (2019) and several researches available in scientific databases also con-
sider the following as potential vulnerabilities or risk factors to drug use: genetic
predisposition, personality traits, presence of mental disorders, negligence or physi-
cal and emotional abuse, social norms and environmental stimuli, lack of knowl-
edge about the substances and their effects and risks, among others.
Therefore, drug use behaviors involve multiple risk factors that deserve attention
from health or related areas professionals. One of those risk factors is the probabil-
ity of occasional use becoming a pattern of abuse and dependence, especially when
experimentation occurs at an early stage of life, between childhood and adoles-
cence, when neurobiological aspects are in process of development and more sensi-
tive to the harmful effects of the psychoactive substances. Another factor refers to
the probability of the use of licit drugs, such as alcohol, to predispose to the use of
other substances, such as illicit ones—many of which have properties with high
action potential to generate dependency. Also, the use of licit drugs can predispose
to the use of more than one drug at once, which can potentialize the negative effects
of the drugs and increase its risks. This information serves as an alarm for policies
to prevent the use of alcohol and tobacco among the young population, since it is
difficult for someone to begin consumption by trying cocaine or LSD, for example.
Another risk factor is the chemical property of the psychoactive substance and its
specific mechanism of action in the CNS, especially when it occurs in the brain’s
reward system, situation in which the drug usually generates a sensation of pleasure
and, consequently, a willingness to consume it again. This, together with personal-
ity factors, life history, environmental and cultural context, sets the user’s “drug of
choice.”
According to the action in the brain, each substance will produce effects, desir-
able and undesirable, manifested under the form of signs and symptoms. The effects
and risks of some of the main psychoactive drugs will be presented below.

Alcohol

Alcohol is a licit drug that has depressant action in the CNS. This means that the
effect of its consumption is the reduction or inhibition of the activity of the CNS,
especially, in the psychomotor activity. It is important to highlight that the level of
alcohol consumption symptoms is directly related to the amount of alcohol ingested
and present in the bloodstream (Abrahão et al., 2012; Nicastri, 2012). Initially,
8 R. A. Reichert et al.

when there is low alcohol content in the blood, the first sensations are euphoria and
disinhibition, as happens with CNS stimulant drugs, but these effects are due to the
depressant action of alcohol in the prefrontal cortex, making inhibitory control, and
some cognitive functions, slower.
Other common symptoms when there is little or moderate alcohol intake include
impaired sensory functions, reduced motor coordination and speech and decreased
attention. On the other hand, symptoms associated with high levels of the drug in
the blood are usually associated with nausea and vomiting, double vision, coma,
and, in extreme cases, hypothermia and death due to respiratory or cardiac arrest
(Andrade et al., 2011; Diehl et al., 2019; Gilpin & Koob, 2008; Guimarães, 2013;
Nicastri, 2012; Tabakoff & Hoffman, 2013). For this reason, from the point of view
of its effects, alcohol is considered a biphasic substance since in low doses it pro-
duces euphoria and in high doses it produces CNS depression.
The continuous and abusive use of alcohol can increase the user’s tolerance to
the drug effects, impelling to the ingestion of larger quantities or to the increasing
of use frequency of the drug in order to satisfy the needs or desires for it, and con-
sequently, promoting its dependence. When it is intended to cease the drug use, the
user can experience an abstinence syndrome, which can be characterized by the
effects that occur with the user due to the lack of the drug in the body (Becker, 2008;
Diehl et al., 2019; Simons et al., 2009).
Even when just the occasional use of alcohol occurs, there are still behaviors
considered “at risk” linked to its consumption. For example, if a person drinks alco-
hol and drives, regardless of the amount, the effects produced can be fatal, since the
reflexes become slower and the visual acuity decreases. Data suggest that in a range
of 33 to 69% of fatal traffic accidents, drivers are under the influence of alcohol
(Sordi et al., 2012). In addition, the chronic use alcohol can affect several organs
and tissues, increasing the probability of development and aggravation of organic
problems, such as gastritis, pancreatitis, cardiac arrhythmias, hepatitis, alcoholic
cirrhosis, CNS lesions, changes in cognitive functions, among others (De Micheli
et al., 2015; Diehl et al., 2019; Masur & Carlini, 2004; WHO, 2009, 2018).
Masur and Carlini (2004), from the question “Cigarette, alcohol, marijuana,
cocaine, heroin: which is the worst? (p. 17), made a comparison of the short- and
long-term damage caused by different psychoactive substances. The damages were
evaluated in five dimensions: (1) organic consequences of chronic use; (2) absti-
nence syndrome; (3) social interaction deficits; (4) risk of overdose; and (5) conse-
quences associated with the route of administration. In the items 1, 2, and 3 alcohol
occupied a prominent position.
Furthermore, studies indicate positive correlations between chronic alcohol use
and structural and functional changes in the brain. Neuroimaging tests suggest that
abusive alcohol consumption, especially when started early, presents impacts on the
development of certain brain regions, what can promote harmful cognitive changes
and negative impacts on people’s academic, professional, and social areas of life.
With technological advances and the possibility of new researches, new studies
have been exploring these indicators in order to better explain these correlations
(Takagi et al., 2014) (Table 1.2).
1 Drug Abuse: Classifications, Effects and Risks 9

Table 1.2 Combined use of alcohol and other substances

Alcohol +
Combination Effects and Risks
GHB, ketamine, It can generate major health risks such as cardiac arrest, reduced heartbeat,
and other and coma.
depressants
Cocaine and other It can cause a false sense of sobriety, and greater consumption of both can
stimulants occur, causing risks of arrhythmia, coma, and cardiac arrest. the combined
use of alcohol and cocaine causes the liver to produce an active metabolite
called cocaethylene, a toxic substance to the cardiovascular system,
associated with convulsions and damage to the liver.
Marijuana, LSD, It can cause unusual reactions of perception, impacts in the analysis of the
MDMA, and other reality and in the judgment of situations and risk behaviors.
psychedelics
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)

Tobacco

There are several variations in tobacco consumption. The most common form is
inhaled, which includes industrialized cigarettes, straw cigarettes, among others.
However, there are also other consumable forms, such as vacuumed and chewed
(Lopes et al., 2012; Pressman & Gigliotti, 2019). Regardless of its consumable
forms, the substance present in its composition that is responsible for causing addic-
tion is nicotine, a drug with a high potential for developing addiction. As the use of
it becomes more frequent, the body’s tolerance to nicotine increases and this makes
the person need to ingest more and more to obtain the expected effect.
A person with nicotine addiction usually presents three types of symptoms:
physical, behavioral, and psychological. The physical symptoms, such as insomnia,
increased appetite, dizziness, and shortness of breath, usually occur when the per-
son is a long period without smoking (abstinence syndrome). Behavioral depen-
dence symptoms occur through associations between smoking and some daily
behavior (e.g., coffee and cigarettes). Thus, if a person smokes a cigarette every
time he/she wakes up in the morning, this behavior is likely to become a habit and
the act of waking up in the morning, then, becomes a trigger for smoking behavior.
Finally, psychological dependence symptoms refers to aspects about what role ciga-
rettes play in a person’s life (França et al., 2015). Thus, if someone smokes when-
ever they feel lonely, the cigarette occupies the function of company for these
moments of loneliness. All these associations happen involuntarily and make the
consumption cessation process difficult.
Due to the action of nicotine in the brain’s reward system, occasional use can
soon become abuse and evolve into addiction, called smoking addiction (APA,
2014), which is considered the world’s largest avoidable cause of death (Pressman
& Gigliotti, 2019). The Pan American Health Organization (PAHO) estimates that
smoking is responsible for 12% of the world’s adult mortality. It is also estimated
10 R. A. Reichert et al.

that there are about 1 billion smokers worldwide and that most of them are concen-
trated in countries considered underdeveloped, which makes the low-income popu-
lation the most affected by tobacco-related diseases (Santos et al., 2018).
The diseases associated with smoking are numerous and frequent, and generate
high costs to the economy. Among them, cardiovascular diseases, respiratory dis-
eases, effects related to reproductive functions (such as miscarriage), as well as
several types of cancer (mouth, lung, pharynx, among others) (Lopes et al., 2012;
Santos et al., 2018). In addition, research suggests that the effects of cigarette smoke
for passive smokers are as harmful as they are for smokers, as they have a higher
risk of developing the same tobacco-related diseases (Lopes et al., 2012; Pressman
& Gigliotti, 2019).

Marijuana

Marijuana has been known and used by human beings for thousands of years for
medicinal, religious, and recreational purposes, among others; it is also one of the
illicit drugs most consumed by the Brazilian population and the world population to
date (Sordi et al., 2012; UNODC, 2019, 2020). Like the other substances, its effects
depend on factors such as quantity, preparation mode, and administration form
(chewed leaf, inhaled or ingested via cake, among other forms), also of the sensitiv-
ity, expectations, and previous experiences of each person, besides the context in
which the consumption occurs.
Its effects generate changes in cognitive, psychological, physical, and behavioral
terms. They can include intensification of the perception of internal stimuli, such as
light and fluctuating body sensations, and distortions in external stimuli, referring
especially to time and space, with the possibility of causing hallucinations; as well
as alterations in memory. The psychobehavioral effects usually include sensations
of relaxation, euphoria and mood swings, disinhibition, and relaxation. The physi-
cal effects usually involve dry lips, tachycardia, conjunctival hyperemia (redness of
the eyes), and bronchodilation, and also psychomotor and speech retardation
(Barlow & Durand, 2015; De Luca et al., 2017; De Micheli et al., 2015; Guimarães,
2013; Masur & Carlini, 2004).
These changes occur as a consequence of the mechanism of action of tetrahydro-
cannabinol (THC, Δ9-tetrahydrocannabinol), the main active component of mari-
juana, in cannabinoid receptors, substantially in regions such as the limbic and
cortex system, associated with memory functions, perception, and sensation of
relaxation and pleasure (Sordi et al., 2012). Interestingly, the body produces natural
(endogenous) versions of cannabinoid substances, called endocannabinoids, such as
anandamide, known in science as the neurotransmitter of happiness or bliss
(Bedendo et al., 2017; Costa et al., 2011; Francischetti & Abreu, 2006).
According to some studies, the chronic or abusive use of marijuana can cause
damage to short-term memory, concentration capacity, and reversible hormonal
changes, as well as social, academic, and professional losses (Sordi et al., 2012).
1 Drug Abuse: Classifications, Effects and Risks 11

There is also evidence that continued exposure to marijuana smoke can cause respi-
ratory infections, as occur with people who smoke tobacco. However, further
research is still needed to better investigate the relationship between marijuana use
and these observed effects.
In addition, the long-term use of the substance may lead to the development of
tolerance (more doses for the same effect) and abstinence, such as manifestation of
anxiety, irritability, insomnia, and decreased appetite. However, these symptoms
present low intensity and severity in comparison with other substances and also
depend on the variables mentioned initially, such as the amount used before con-
sumption cessation, period extension of use, and environmental factors (Barlow &
Durand, 2015; Bonnet & Preuss, 2017; Guimarães, 2013; Masur & Carlini, 2004).
In terms of psychological and behavioral dependence, marijuana seems to play
important roles in social rituals and situations, presenting an especially strong influ-
ence among young people.
With regard to brain impacts resulting from the chronic use of marijuana, Crippa
and collaborators (2005) indicated that the results of neuroimaging studies are
inconclusive or divergent. Takagi et al. (2014) stated that the limitations of these
studies refer to small, cross-sectional samples, which do not investigate drug abuse
in a longitudinal manner. In addition, the authors note the association between drug
abuse and psychiatric comorbidities, which may explain the morphological differ-
ences presented by the tests (the literature suggests that there are brain alterations in
people with anxiety and depression, for example).
Based on this, it is possible that the observed alterations constitute a neurobio-
logical risk factor for drug abuse and not the reverse. The same is true for psychosis,
according to Ksir and Hart (2016a, 2016b). The authors state that although there are
studies showing correlation, there is little evidence regarding the causal nature
between psychosis and marijuana and that its use does not cause a psychotic disor-
der by itself. What seems to happen, based on reviews of studies, is that psychotic
behaviors caused by marijuana use are more likely in subjects who have some prior
history of mental disorder or predisposition to psychosis. However, further studies
are needed to conduct an in-depth investigation of these issues (Table 1.3).
Besides the psychobiological aspects of marijuana use, social-political issues
related to its use should be widely discussed, such as its classification as an illicit
drug and, more recently, its resurgence as a substance with high medicinal potential.
The social pressures responsible for this historical process need to be analyzed and
discussed. Now, after years of research and evidence regarding its positive and

Table 1.3 Combined use of marijuana and other substances

Marijuana +
Combination Effects and Risks
Alcohol It increases the probability of pressure drop, dizziness, and vomiting.
Psychedelics It can intensify the effects of psychedelics, making them unpredictable
and unpleasant.
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)
12 R. A. Reichert et al.

negative impacts on human health, decisions regarding regulatory policies, medici-

nal use, and interventions aimed at education, prevention, and treatment need to be
scientifically grounded. This requires combining studies and experiments with criti-
cal discussions of the facts (Piomelli, 2016).

Solvents and Inhalants

This category includes drugs that are aspirated through the nose or mouth, such as
shoemaker’s glue, loló,2 and perfume launcher, usually soaked in cloths or in the
clothes. They can cause various effects, such as depression, stimulating, and hallu-
cinogenic ones on the central nervous system. These effects can include: (a) initial
excitement, due to the depression of functions in the prefrontal cortex (euphoria,
exaltation, decreased critical judgment, impulsiveness, perceptual changes, etc.);
(b) initial depression (confusion, obnubilation, headaches, etc.); (c) middle depres-
sion (reduced alertness, slow reflexes, lack of motor coordination, nystagmus, etc.);
and (d) deep depression (intense alertness depression, state of unconsciousness with
bizarre dreams and increased possibility of convulsions and alterations in the elec-
troencephalogram) (Masur & Carlini, 2004).
The continuous abusive use of drugs of this category is associated with structural
and functional alterations of brain regions and damages in cognitive functions, such
as attention, memory, and learning, besides tiredness, headaches, motor damages,
and mental confusion. In cases of overdose, it can lead to death by depression and
cardiac or respiratory arrest. Despite this, the consumption of these substances is
common in several places in the world, mainly by children and adolescents with
fewer socioeconomic indexes. In Brazil, they are among the most popular drugs
among public school students, according to studies (Carlini et al., 2010; Masur &
Carlini, 2004; Takagi et al., 2014) (Table 1.4).

Table 1.4 Combined use of solvents or inhalants and other substances

Combination of Solvents
or Inhalants + Effects and Risks
Alcohol Intensification of the depressant effect on the central nervous system,
with the possibility of cardiorespiratory arrest and coma.
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)

2
Loló, also known as Cheirinho-da-Loló (Loló’s smell) is a street drug, common in Brazil region,
which comprises an aerosol of chloroform in ether solution, which can cause cardiac arrest.
1 Drug Abuse: Classifications, Effects and Risks 13

Amphetamines

Amphetamines are part of the group of CNS stimulant drugs and can produce feel-
ings of euphoria and reduce fatigue, sleep, and appetite (APA, 2014). Their mecha-
nism of action involves the release of dopamine, noradrenaline, and serotonin
through the inhibition of the recaptation of neurotransmitters or through the inhibi-
tion of the enzyme monoaminoxidase (MAO), which causes feelings of pleasure,
well-being, and euphoria (Calipari & Ferris, 2013; Faraone, 2018; Marcon et al.,
2012). However, after the expected effects, people usually feel the opposite, i.e. a lot
of tiredness, drowsiness, increased appetite, and more depressed mood (APA, 2014).
Disorders related to the use of these substances include physiological and behav-
ioral symptoms, such as changes in heartbeat or blood pressure, sweating or chills,
weight loss, muscle atony, euphoria or emotional blunting, changes in sociability,
anxiety, tension, anger, and stereotyped behavior (Barlow & Durand, 2015; Muakad,
2013). It is important to note that tolerance to the use of amphetamines develops
rapidly. Due to that, in Brazil, the National Health Surveillance Agency (Agência
Nacional de Vigilância Sanitária – ANVISA) determined, on October 6, 2011, the
prohibition of production, dispensation, import, export, prescription, and use of this
drug because of the associated risks.

Cocaine and Crack

Cocaine is extracted from the plant Erythroxylon coca and can be consumed from
different routes of administration: chewed, in the form of coca leaf; aspirated, in the
form of powder (cocaine hydrochloride); injectable, cocaine hydrochloride dis-
solved in water; and smoked, in the form of crack or merla (coca paste) (Castro
et al., 2015; Nicastri, 2012). Crack is the crystallized form of cocaine and can be
quickly smoked and absorbed by the body as it reaches the bloodstream from the
moment it reaches the lungs.
These CNS stimulant drugs interfere with the action of neurotransmitters. Their
action mechanism involves the drug active property that blocks the receiving pump,
enabling neurotransmitters, such as dopamine, noradrenaline, and serotonin, to
remain in greater quantity and for longer periods in the synaptic clefts. The stimu-
lant effects caused by cocaine/crack consumption involve brain regions such as the
ventral tegmental area (VTA), accumbens nucleus, amygdala, hippocampus, and
frontal cortex. Together (with the exception of the cortex), these regions make up
what is called the “reward circuit” or “pleasure circuit,” which plays a primary role
in the repetitive characteristic of drug seeking and consumption behavior, given that
the high levels of dopamine available in these regions, stand out greatly at levels
related to stimuli/activities involving natural pleasures such as food and sex
(Bedendo et al., 2017; Castro et al., 2015; Nestler, 2005).
From the stimulating action of cocaine/crack in the CNS, physical, cognitive,
psychological, and behavioral effects are observed. The first two include
14 R. A. Reichert et al.

Table 1.5 Combined use of cocaine and other substances

Combination Cocaine + Effects and Risks
Stimulant + depressant False sense of sobriety, increasing the sense of power and
substances (alcohol, increasing the risks of accidents and involvement in other risk
tranquilizers, or perfume situations (violence, for example). In addition, it increases the
launcher) risk of cardiac arrest.
Alcohol The liver produces cocaethylene, a toxic substance to the liver,
the cardiovascular system and that can cause convulsions.
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)

acceleration of heartbeats, pupils dilation, sweating, tremor, dry mouth, decreased

appetite, insomnia, reduction of the critical sense and inhibitory control, alteration
of time reaction, as well as of attention and sense of perception, which can generate
hallucinations and cause panic attacks. The latter two involve feelings of euphoria,
grandiosity and disinhibition, exaggerated alertness, aggressiveness, accelerated
speech and gait, a state of arousal and reduction of tiredness (Castro et al., 2015;
Nicastri, 2012). On the other hand, as the effects cease, unpleasant sensations may
arise, such as intensification of anxiety and depression symptoms (Bedendo et al.,
2017; De Micheli et al., 2015; Masur & Carlini, 2004; Rosário et al., 2019)
(Table 1.5).

Ecstasy

3, 4 - methylenedioxymethamphetamine (MDMA), better known as ecstasy or “bul-

let,” is a drug that generates both stimulant and hallucinogenic effects. This sub-
stance was initially called empathy, due to the increased sociability caused by its
use. The most common form of administration of ecstasy is by oral route, from the
ingestion of tablets of different colors and sizes. However, it can also be inhaled (by
dismantling the pill and aspirating it through the nose). It is a fully synthetic drug,
i.e. produced in the laboratory, so the tablets contain about 50 to 150 mg of the
active substance. The mechanism of action is not yet well established, although it is
known to have important action on serotonergic pathways (Meyer, 2013; Vegting
et al., 2016; Xavier et al., 2008).
Its effects on the brain begin about 30 min after taking the pill and can be classi-
fied into three phases: (a) an initial feeling of disorientation, including changes in
sense of perception, particularly in the sight and touch; (b) intense pleasure, such as
increased positive emotions, extreme well-being, physical disposition, and reduced
fear; and (c) a significant increase in socialization, including improved communica-
tion skills and decreased aggressiveness. Negative physical signs and symptoms
include increased heartbeat, blood pressure, and body temperature, which can lead
to an exacerbated intake of water, resulting in intoxication from excessive consump-
tion and thus considerable changes in the body.
1 Drug Abuse: Classifications, Effects and Risks 15

Table 1.6 Combined use of ecstasy and other substances

Ecstasy +
Combination Effects and Risks
Alcohol Alcohol exacerbates dehydration caused by MDMA. Also, both substances
overload the liver, kidneys, and raise body temperature.
Stimulants Increased blood pressure, cardiac risk, and stroke.
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)

In extreme situations, the use of this drug can lead to malignant hyperthermia
(excessive increase in body temperature), organ failure, induction of coma and
death, risks intensified by the fact that it is an illicit drug manufactured in clandes-
tine laboratories without regulation and quality control (De Micheli et al., 2015).
After the effects, enormous fatigue, muscle pain, nausea, and depressive symptoms
may appear. According to Garcia et al. (2014), the chronic use of this substance is
correlated with changes in the functioning of neurotransmitters such as serotonin
and in cognitive functions such as processing, memory, attention, and learning
(Table 1.6).

LSD

Like ecstasy, LSD (Lysergsäurediethylamid: Lysergic Acid Diethylamide) is a syn-

thetic drug, of the class of those that generate problems to the CNS. The form of
presentation of LSD is also in tablets or small papers (stamps) that contain the syn-
thesized acid. Doses between 75 and 200 mg of this drug are already capable of
causing changes in the state of consciousness and hallucinogenic effects. The dura-
tion of the effects is quite prolonged when compared to cocaine/crack, for example,
and can vary between 4 and 12 h, being more intense after 2 h of ingestion (Passie
et al., 2008). The user’s goal is usually to obtain hallucinations, changes in the state
of consciousness and perception.
The mechanism of action is not well known, what is known is that it acts in the
CNS disturbing qualitatively and quantitatively the functioning of the brain and
provoking physical, cognitive, psychological, and behavioral alterations. The main
physical signs and symptoms include pupil dilation, increased blood pressure and
heartbeats, dry mouth, loss of appetite, and sleepiness. The others involve changes
in consciousness, perception (of time and space, alteration of senses, colors, shapes,
and contours), and thinking, including persecutory delusions and hallucinations, as
well as mood swings and states of exaltation, which can be positive or negative
(“good or bad travel”).
Toxic or negative effects commonly reported are intense crises of anxiety, dis-
tress, panic, depression, and psychotic conditions, including “flashbacks,” which
are presentations of sudden signs and symptoms of the psychic effects of the drug
experience without having consumed the substance again. On the other hand, there
16 R. A. Reichert et al.

Table 1.7 Combined use of LSD and other substances

LSD/NBOM
Combination + Effects and Risks
Alcohol The effects can be diverse and make the experience unpredictable.
Stimulants It can amplify the stimulating effects of LSD and related drugs and
generate risks such as increased blood pressure and cardiorespiratory
arrest.
Psychedelics Intensification of the effects, which can generate, in some cases, states of
mental confusion, delirium, and psychotic crisis.
Source: É de Lei (Brazilian organization whose aim is to promote the reduction of health and social
risks and harms through support in formulating drug-related policies. Site: https://edelei.org/)

is no consistency in the literature on substance dependence on LSD, and the greatest

risk related to its consumption is associated with the triggering of psychosis and
mood swings in individuals predisposed to these disorders (Nicastri, 2012; Passie
et al., 2008) (Table 1.7).

Final Considerations

In order to avoid reductionism on a multifactorial issue such as the use of psychoac-

tive substances, it is important to emphasize that their effects and risks are influ-
enced by the interaction of a series of biological, psychological, and sociocultural
factors. It is, thus, a biopsychosocial issue. Therefore, in order to assess the damage
resulting from the drug use, the context, the quantity used, the frequency, the age of
initiation, the level of damage in work, in academic and in social activities, and
other several variables must be taken into consideration.
In the political-criminal context of drugs, which starts from the prohibitionist per-
spective and the incessant and inefficient fight against consumption, it becomes more
difficult to measure the effects and risks resulting from the use of psychoactive sub-
stances and their original active principles, since there is no formal regulation and
control of the production process of these drugs. In other words, there is a lack of
knowledge about the composition of most substances that are widely used in various
contexts of socialization. This, in addition to hindering research and, consequently,
the formulation of effective intervention strategies, can generate a series of damages
to human health (as observed throughout this chapter), which could/can be avoided or
reduced with policies of control, prevention, and reduction of risks and harm.
In any case, when talking about potential risks associated with drug use, one can
compare the behavior to common everyday habits, as the American neuroscientist
Carl Hart (2019) does.3 According to the researcher, for everything in life there is a

3
Lecture given at the VII International Congress of the Associação Brasileira Multidisciplinar de
Estudos sobre Drogas / Brazilian Multidisciplinary Association of Drug Studies (ABRAMD), in
Curitiba (Paraná, Brazil) in June 2019.
1 Drug Abuse: Classifications, Effects and Risks 17

risk; and what maintains a behavior is its function. Driving cars and traveling by
plane, for example, are habits that, in some way, may represent certain risks, but
they are maintained because they are functional for human life; the same occurs in
relation to the use of substances. In this sense, as well as education and awareness
about other habits that can mean some risk to physical or psychological integrity,
the conscious use of psychoactive substances should be discussed in order to pre-
vent adverse consequences to the users and others. To this end, prevention and
health care programs should be implemented in various areas of society, especially
in educational settings. It is essential that these programs are evidence-based and
periodically evaluated to measure their results.

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Chapter 2
Behavioral Analysis of Substance Use
and Dependence: Theoretical-Conceptual
Aspects and Possibilities for Intervention

Richard Alecsander Reichert, Simone Martin Oliani,

and Roberto Alves Banaco

Introduction

The use of substances to alter behavior, whether in terms of perception, degree of

consciousness, or emotional state, is an ancient social practice in the history of
mankind. Substance consumption took on a greater proportion in Western society at
the end of the nineteenth century, spreading from the 1960s and on (Bergeron,
2012). Currently, harmful use and dependence are a major public health concern,
insofar as they can have effects at the individual and social level (UNODC, 2019;
WHO, 2018). Problems regarding the use of these substances are related to daily
behaviors, such as drinking alcohol, smoking cigarettes, and consuming other drugs.
Although common, these behaviors can progress from substance use to substance
dependence and generate or intensify adverse consequences, represented by per-
sonal, family, academic, professional, financial, emotional, and social losses
(Barlow & Durand, 2015).
Drug addiction was once considered a moral problem or character deficit.
According to the popular notion, predominant mainly in the mid-nineteenth century,
substance-dependent individuals consumed substances by free will, being

R. A. Reichert ()
Department of Psychobiology, Universidade Federal de São Paulo (UNIFESP),
São Paulo, SP, Brazil
e-mail: [email protected]
S. M. Oliani
Centro Integrado de Neuropsiquiatria e Psicologia Comportamental (CINP),
Londrina, PR, Brazil
e-mail: [email protected]
R. A. Banaco
Paradigma – Centro de Ciências e Tecnologia do Comportamento, São Paulo, SP, Brazil
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 21

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_2
22 R. A. Reichert et al.

stigmatized as indecent or sinful. In this perspective, it was believed that people

could decide whether or not to ingest drugs and, due to the immoral character, con-
sumed them (Garcia-Mijares & Silva, 2006). Bergeron (2012) indicates, in this
explanatory conception for the problem with drugs, a dualistic notion, which values
notions of integrity, conscience, autonomy, and the sovereign nature of the human
being. This view of dependency as a deviation or immoral standard of conduct may
be based on the notion of free will, which Baum (2018) describes as simply being a
name for the lack of knowledge regarding the determinants of behavior.
Several theoretical models have been developed with the goal of explaining the
use and dependence on substances that alter behavior in terms of consciousness,
perception, and emotions. However, many of these theoretical models approached
the subject in a quite reductionist and simplistic manner, disregarding the variability
of personal and contextual factors and the different dimensions involved. Different
perspectives on substance use and dependence have emerged over time, some of
which are shown in Table 2.1.
As Table 2.1 shows, there are many conceptions about substance abuse that have
been associated for a long time. Several studies have been carried out in order to
better understand the issues related to substance use. In addition to confirming its
complexity and its multifactorial nature, these researches demonstrated the role of

Table 2.1 Theoretical models of substance use and dependence

Moral model In the moral model, both substance use and dependence are considered
personal choices. This behavior is believed to be a disregard for social
norms. for this reason, users are the target of criticism, inattention, and
punishment.
Temperance or The temperance model emerged at the end of the nineteenth century, being
sobriety model the first structured attempt to understand the etiology of alcohol
dependence. According to this model, addiction is not a moral failure or a
sin, but a habit to be unlearned through a balance in consumption.
Neurological According to this model, based on a study published in 1849, in Sweden,
degeneration model alcohol dependence should be understood as a pathology, and the
treatment should be similar to other diseases of the time (steam baths,
using leeches, etc.).
Spiritual model In this model, alcohol dependence is seen as a condition in which the
individual becomes unable to overcome by oneself, being necessary to
surrender one’s life to a higher power to then proceed with the recovery.
Psychological The psychological model encompasses several schools of thought that
model seek to explain the development of substance dependence, such as the
cognitive-behavioral model, the psychoanalytic school, the social learning
model, the systemic model, among others.
Biological model The biological model suggests physiology and genetics as factors
responsible for the etiology of substance dependence.
Biopsychosocial The biopsychosocial model states that substance dependence is
model multifactorial and therefore, a multilevel analysis (integrating different
theories) would be necessary to understand the etiology of substance
dependence.
Sources: Cordeiro (2018) and Perrenoud and Ribeiro (2019)
2 Behavioral Analysis of Substance Use and Dependence: Theoretical-Conceptual… 23

the social context in the installation and maintenance of these behavior patterns. An
important study, known as “Rat Park,” was carried out by Alexander, Coambs, and
Hadaway in the 1970s. Upon realizing that experimental subjects used in laborato-
ries were kept in environments quite different from their natural habitat, the
researchers investigated whether environmental conditions as social isolation and
the absence of alternative reinforcers would be predictors of substance use and
dependence and if the presence of these stimuli could interfere with the choice of
using drugs.
The goal of the study was to compare the rates of self-administration of mor-
phine between two groups: (A) isolated and stimulus-deprived rats in laboratory
cages and (B) rats living socially in an environment with the availability of alterna-
tive reinforcers. The results showed that rats that were isolated and without access
to other reinforcers ingested significantly higher rates of the morphine solution
available in both cages, which can be explained by the potentiation of the reinforc-
ing effects of morphine in relieving aversive sensations resulting from adverse envi-
ronmental conditions (Alexander et al., 1978; Gage & Sumnall, 2018). In line with
these data, studies by other theorists from different fields of knowledge, such as
Howard Becker (Outsiders: Sociology of Deviation Studies, 1963) and Norman
Zinberg (Drug Set and Setting: The Basis for Controlled Intoxicant Use, 1984),
reiterate the need to consider contextual aspects, in addition to the pharmacological
characteristics of substances, when analyzing behaviors and social practices such as
the drug use.
Further research and discussions highlight some methodological weaknesses of
some similar experiments, in addition to the fact that other studies present divergent
results. Regardless, there is a consensus in the scientific literature the idea that the
behavior must be analyzed, in this case different patterns of substance use, consider-
ing the environmental influence, thus adopting a biopsychosocial perspective, that
is, considering the interrelation between biogenetic and psychosocial variables.
This new perspective enables the development of more integrative and effective
protection, prevention, and treatment strategies at the individual and collective level.

The Approach Proposed by Behavior Analysis

A theoretical approach that recognizes the multidetermination and complexity of

the behavior, covering psychosocial variables, in addition to biological ones, is the
explanatory model of behavior analysis. This approach is a behavioral science based
on the philosophical assumptions of radical behaviorism, of which Burrhus Frederic
Skinner (1904–1990) was the driving force.
One of his influences was I. M. Sechenov (1829–1905), a Russian physiologist
who developed one of the first explanatory models of behavior through the concept
of reflex. His doctoral thesis, published in 1860, was entitled “Data for the future
physiology of alcohol intoxication.” The researcher sought to explain the behavior
through organism–environment interaction, considering historical-environmental
24 R. A. Reichert et al.

factors, because, in his perception, an organism cannot live without the external
environment. Therefore, a scientific explanation of the organism must consider the
context in which it is inserted. Sechenov was an influence for Ivan Pavlov (known
for his studies on classical/respondent conditioning) who, in turn, was an influence
for Skinner (Pessotti, 2016).
Skinner (2006) defines behaviorism as the philosophy of behavioral science.
This means that when talking about behaviorism, philosophical issues are on the
agenda, that is, questions that guide and clarify the way we understand the world.
The conception of human beings in radical behaviorism starts from the principle
declared by Bertrand Russell, in his 1927 book “Outlines of Philosophy.” In the
chapter entitled “The role of the environment,” Russell questions Watsonian behav-
iorism, which followed the same principles already described earlier by Sechenov
and Pavlov: the relationship in which the environment determines the activity of
organisms was only a part of the complex existing relationships. There were also the
relationships in which organisms change the environment through their actions, and
this altered environment, in turn, would also affect human activities… (Botomé
et al., 2018).
These assumptions, supposed and developed by Skinner, refer to an approach to
the functioning of the organism from a broader perspective, taking in consideration
the organism and also the environment in which it is inserted, and which operates
on it, as previously described (Moreira & Hanna, 2015; Pessotti, 2016; Skinner,
1957, 2003, 2006).
The behavior analysis, a science of behavior based on the philosophical princi-
ples of radical behaviorism, was inspired by the Darwinian concept of evolution of
the species, which proposes the occurrence of morphological, physical, and intra-
and intergenerational variations of individuals, and it is up to the environment to
select individuals with characteristics better suited for survival. For this approach,
science, more specifically the science of behavior, must look for the relationships
between the natural events that influence human action, and are influenced by it, and
that is why it is mandatory to recognize the role of the environment.
At the behavioral level, all individuals have variations in the way they behave,
and the environment selects and maintains the most appropriate responses to that
environment. Finally, given that the environment outside the organism is essentially
composed of other humans, the social level must also be considered in the analysis
to be elaborated (Banaco & Montan, 2018; Baum, 2018; Moreira & Medeiros,
2018; Skinner, 2003, 2006). Behavior is determined by multiple factors and, for this
reason, a multilevel analysis is essential.
This theoretical model considers, therefore, the interaction between phyloge-
netic, ontogenetic, and sociocultural variables as determinants for the behavior.
According to Skinner (1974/2006, p. 163), “a scientific analysis of behavior must
[…] assume that a person’s behavior is controlled more by his genetic and environ-
mental history.” For Skinner (1951/2003), what the human being does is the result
of conditions that can be specified. The author points out that “circumstances
beyond the individual are important” (p. 9) as opposed to the tendency to seek
explanations for behavior exclusively within the organism.
2 Behavioral Analysis of Substance Use and Dependence: Theoretical-Conceptual… 25

Admitting that the role of science is to relate events, making arrangements of

variables and verifying their changes, as well as establishing new relationships, it is
a role of behavior analysis—the science of behavior—to identify the variables that
control behavior, to then predict the likelihood of its occurrence. For that purpose,
what people do, talk, think, or feel must be contextualized. That is why, behavior
analysts define psychology as the science that studies the behavior of organisms in
relation to the environment in which they are inserted, that is, the behavior–environ-
ment interactions are studied (Lombard-Platet et al., 2015; Moreira & Hanna, 2015).
In summary, the radical behaviorist and analytical-behavioral perspective (a)
takes determinism in consideration when explaining facts of human nature, adopt-
ing a monist conception and favoring direct observation; (b) understands introspec-
tion as a way of recognizing private human events, and not as an investigative
method or procedure; (c) proposes studying behavior in the context of the relation-
ship between organism and environment; (d) highlights the importance of an acces-
sible and functional form of research and, above all, that is applicable to any contexts
where there are relationships between organism and environment that explain the
installation and maintenance of behavior; (e) adds the functional possibility of the
principles that guide behavior science, making it possible to solve both individual
and collective/social issues; (f) reveals the existence of the operant behavior and
takes it as the main focus of the investigations, recognizing and describing the sev-
eral schedules and operations that can alter the probability of the behavior occurring
and explaining its functionality; (g) starts from the assumption that, under certain
contextual conditions, consequences follow responses; (h) sees the applicability of
the three-term contingency paradigm to the analysis of social issues and cultural
practices; and (i) has developed essential concepts such as modeling, social behav-
ior, verbal behavior, and other essential terms for behavioral analysis (Carrara, 2016).
The analytical-behavioral theory studies the behaviors through the experimental
method, and its interventions are based on the findings obtained through it. The
behavior analysis, therefore, seeks to understand the relationships between the
actions of the organism and the changes in the environment in which the latter is
inserted, investigating the conditions responsible for the recurrence of certain
responses. As for substance use and dependence, a broad and varied interpretation
is sought, understanding that the behaviors are multifunctional. From the identifica-
tion of environmental variables that influence behavior, it is possible to manipulate
them and develop assertive behavioral strategies for the management of contingen-
cies previous to problem behavior (Banaco & Montan, 2018) (see Fig. 2.1).
Behavior analysis has a wide range of research and evidence that define behavior
as a product of mutual and complex interactions between phylogenetic, ontogenetic,
and sociocultural variables. This theoretical model allows a broader understanding
of behaviors such as drug use and dependence and emphasizes the context and envi-
ronmental factors as the focus of more effective interventions, identifying and mod-
ifying the contingencies responsible for the installation and maintenance of
behaviors, thus providing environments that facilitate learning new responses favor-
able to both individual and collective well-being.
26 R. A. Reichert et al.

Fig. 2.1 Issues that guide

the work of behavior
analysts. (Source: Banaco
and Montan 2018)
What environmental
variables does the
behavior depend on?

What changes occur What manipulaons

in the environment can be made to
that produce the prevent this behavior
behavior? from taking hold?

A topic which was previously understood in a restricted way has begun being
analyzed scientifically in a broader way (biopsychosocial). Understanding the phe-
nomenon from the analysis of the relationships established between the organism
and environment and by identifying the variables that control the behavior, as well
as recognizing the specific changes occurred in the central nervous system using
psychoactive drugs, Skinner’s maxim is recognized: the behavior is multideter-
mined. The integration of neuroscience with behavioral theories and approaches is
a highly relevant interdisciplinary field and is part of the changes regarding the
progressive understanding of substance use and dependence. The functional defini-
tion of addiction emerged as an alternative perspective based on scientific evidence,
breaking with views that, being partial and limited, have not, so far, found good
answers to this problem. The attempt to recognize the multifunctionality of human
behavior tries to fill this knowledge gap regarding different sciences, since the sub-
ject is too broad to fit within one science only. Behavioral pharmacology, for exam-
ple, is a field of study that starts from these premises and demonstrates the
complementarity between behavior analysis and physiology, also showing how
environmental variables can play a role in the effects created by psychoactive sub-
stances, as it is understood that setting some boundaries to the study on the function-
ing of drugs to merely neurobiological aspects produces incomplete knowledge on
the subject. These advances make it possible to develop new behavioral and phar-
macological technologies for the treatment of disorders related to substance use
(Garcia-Mijares & Silva, 2006; Leonardi & Bravin, 2012; Maté, 2010).
This book aims to demonstrate several ways of approaching such a plural sub-
ject. Part I covers introductory aspects and main concepts, and approaches it in a
more general and comprehensive perspective. Distinct ways of identifying sub-
stance abuse are presented, as well as the excessive aspect that classifies it as patho-
logical (Chap. 1); behavioral use and dependence as well as possibilities for
2 Behavioral Analysis of Substance Use and Dependence: Theoretical-Conceptual… 27

intervention are analyzed (Chap. 2); in addition to analyzing the diagnostic criteria
for substance use disorders from an analytical-behavioral perspective (Chap. 3).
Also in this Part, the basic concepts of behavioral pharmacotherapy can be found
(Chap. 4); as well as the functional analysis of substance use and dependence (Chap.
5); and a discussion regarding the establishment and abolition of contingencies for
the use of crack (Chap. 6). fvNext, in Part, the reader will find chapters that focus
on contributions from clinical and social interventions, where they deal with the
case analysis and demonstrate how to identify, develop a case formulation and pro-
posals for treatment, as well as to evaluate the results of the interventions. The
proposals listed are Contingency Management (Chap. 7), Exposure Therapy with
Response Prevention (Chap. 8), Functional Analytic Psychotherapy - FAP (Chap.
fv9), Dialectical Behavior Therapy – DBT (Chap. 10), Acceptance and Commitment
Therapy – ACT (Chap. 11), Reinforcement Contingency Therapy (Chap. 12), and
Motivational Interviewing (Chap. 13). Finally, in Part, special topics are presented:
the interfaces between neurosciences and behavior analysis on drug use and depen-
dence (Chap. 14); behavioral proposals to provide guidance and solution to issues
related to the analysis of other behavioral excesses in humans (Chap. 15); marital
narratives in detecting and developing substance abuse (Chap. 16); effects of sub-
stance use in romantic relationships and their relationship to violence against
women (Chap. 17); and the availability and difficulty of detecting alcohol and
tobacco abuse at the clinical level (Chap. 18).

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(Eds.), O tratamento da dependência química e as terapias cognitivo-comportamentais: um
guia para terapeutas (2nd ed., pp. 115–132). Artmed.
Barlow, D., & Durand, V. (2015). Psicopatologia: uma abordagem integrada (7th ed.). Cengage
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Chapter 3
Criteria for Substance Use Disorders
Diagnosis (SUD): An Behavioral-Analytic
Perspective

Fábio Henrique Baia, André Amaral Bravin, Wilson Benício Martins,

and Rogério Guaita dos Santos Baia

Introduction

The Diagnostic and Statistical Manual of Mental Disorders - DSM-V (APA, 2014)
and the ICD-10 Classification of Mental and Behavioral Disorders (WHO, 1993)
present diagnostic criteria for “substance-related disorders” or “mental and
behavioral disorders due to the use of psychoactive substance,” respectively. The
criteria used in these manuals conflict with the perspective of radical behaviorism
(RB) 1. However, Souza (2003) points out that, despite these problems, the manuals
facilitate communication among professionals in different areas. The objective of
this work is to present to analytical-behavioral therapists possible functional
understandings of diagnostic criteria for substance use disorders. The understanding
of the variables involved in determining these behaviors can facilitate the practice of
therapists and allow improved communication with other health professionals.

1
See Banaco et al. (2010) and Cavalcante and Tourinho (1998).

F. H. Baia ()
Universidade do Rio Verde (UniRV), Rio Verde, GO, Brazil
Universidade de São Paulo (USP), São Paulo, SP, Brazil
e-mail: [email protected]
A. A. Bravin
Universidade Federal de Jataí, Jataí, GO, Brazil
W. B. Martins · R. G. dos Santos Baia
Universidade do Rio Verde (UniRV), Rio Verde, GO, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 29

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_3
30 F. H. Baia et al.

Disorders Related to Substance Use

There are two reasons for choosing DSM-V (APA, 2014) as the main thread of this
analysis, namely its recenticity and its harmonization with the International
Classification of Diseases (ICD). It is known that in addition to the task of classifying
diseases, both manuals present statistical, epidemiological, developmental aspects.
Considering that the most current version of the DSM (APA, 2014) was published
20 years after the most current version of the ICD (WHO, 1993), this is the most
recent of the two manuals, and this is the first reason that justifies the present choice.
The second reason is the recognition that one of the objectives of the DSM-V was
its harmonization with the ICD (APA, 2014). Thus, the professional who eventually
needs the ICD-10 codes for his or her trade will be able to do so by consulting the
new version of the DSM (APA, 2014), the opposite being impossible. This
harmonization makes it possible to extend the behavioral interpretations carried out
here to include the descriptors of ICD-10 (WHO, 1993).
The diagnostic criteria for substance dependence of DSM-V follow a descriptive
logic, and were organized among those behaviors that indicate (a) “low control over
substance use” (criteria 1 to 4), (b) “social harm” (criteria 5 to 7), (c) “risky substance
use” (criteria 8 and 9), and (d) “pharmacological criteria” (criteria 10 and 11) (APA,
2014). However, this organization appears to rely more on topographic than
functional aspects of behavior2. The following are the diagnostic criteria agglutinated
by possible functional interpretations of the behavioral processes involved.
Criterion (1): The substance is often consumed in larger quantities or over a
longer period than intended.
The use of the substance in quantities or periods longer than intended may lead
to interpretations of forces explaining behavior as “intention.” Intention as a causal
force is incompatible with the behaviorist radical notion of the determinant variables
of behavior. Radical behaviorism advocates explanations based on functional
relationships between behavior and the environment, so it rejects any explanation
that establishes mental causes as determinants of behavior (Moore, 2008). According
to Hineline (2003), it is possible to understand intentional verbalizations as long as
no causal forces are attributed to these statements. According to the author,
“statements of intent are in themselves behavioural events, and should be considered
as such” (p. 210). To understand intentional statements the author uses verbal
relations. Declaring intention is a verbal behavior controlled by environmental
events. When someone says they will consume only two shots of whiskey, this
verbal behavior is controlled by past environmental events. To give an example,

2
The current version of DSM-V presents diagnostic criteria that “cover 10 distinct classes of drugs:
alcohol; caffeine; cannabis; hallucinogens […]; inhalants; opioids; sedatives, hypnotics, and anx-
iolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and
other substances”. For the preparation of this chapter, the criteria that are repeated in most of the
diagnoses for substances were chosen. Thus, specific criteria such as gastrointestinal discomfort of
caffeine were discarded from the synthesis presented here.
3 Criteria for Substance Use Disorders Diagnosis (SUD): An Behavioral-Analytic… 31

saying “I will only drink two shots” to a given individual can be functionally
equivalent to saying “in the past, when I was at a party and whiskey was present, I
drank two shots and had my behavior reinforced by social acceptance from my wife,
so when I am in similar situations such as party, whiskey and wife, I am likely to
reemerge the two shots behavior.” Note that the intent is neither causal force nor
verbal descriptions controlled by future events.
Still according to Hineline (2003) when someone declares an intention to do
something, it is possible that such a declaration alters the probability of the declared
behavior occurring. Thus, when a person arrives at the party who has previously
declared that he would only consume two shots of whiskey, he may have his behavior
controlled by such a declaration. The previous declaration can act as a function
altering stimulus, since consuming more than the declared one can lead to positive
punishments such as fights by the wife for the lack of correspondence between what
was said and what was done.
Thus, verbal correspondence studies can help to understand the determinant vari-
ables of verbal statements (saying behavior) and their correspondence/non corre-
spondence with doing behavior (Beckert, 2005). The understanding of events that
determine the verbal correspondence of the type say-do helps in the functional inter-
pretation of the symptom of consuming substance above the intended. Non-­
correspondence may occur due to contingent reinforcements to this situation. For
example, the verbal response of declaring a given consumption may be under
control of events as social reinforcement. However, the behavior of consuming
substance is controlled by reinforcements produced by the substance itself (e.g., the
relief of withdrawal symptoms). In this case, verbal responses (intention to consume)
and nonverbal responses (consumption) have different controls, which may lead to
a mismatch between saying and doing. It is up to the behavioral therapist to
understand how reinforcements produced by ingestion of substance outweigh
reinforcements of the tell-to-do correspondence. A possible strategy for treatment
could involve scheduling boosters for verbal tell-to-do correspondence so that such
boosters compete with the consequences of consuming the drug at higher doses than
declared.
Criteria 2 and 4: (2) There is a persistent desire or unsuccessful effort to reduce
or control the use of the substance; and (4) There is a crack or a strong
desire or need to use the substance
Both criteria, 2 and 4, point to the role of “desire“ in the diagnosis of substance
dependence. While criterion 2 argues for a desire to reduce or control substance use,
criterion 4 argues for a strong desire to use it. This strong desire (designated as a
craving) is defined as an uncontrollable need for drug use and has been held
responsible for relapses, i.e. unsuccessful efforts to reduce or control use. Thus, a
relationship is observed between both diagnostic criteria, and for this reason it
seems more appropriate to present them on the same topic.
Skinner (1974/2006) states that the term desire should be understood as the prob-
ability of the behavior occurring. Thus, when referring to the existence of a persis-
tent desire, the individual reports the control that an environmental event exerts over
32 F. H. Baia et al.

its response. Saying that he wishes to consume substance describes that there is a
high probability of the consumption behavior occurring. Therefore, the behavior
analyst should investigate the factors that are determining the probability of the
behavior occurring.
The lower interruption or consumption behavior depends on environmental
events. The interruption may occur by positive social reinforcement such as
compliments released by other people (e.g., the companion, children or friends may
say how they observed improvement in user behavior due to interruption or reduced
use), or nonsocial reinforcement (e.g., improved attendance and frequency at work
or improved ability to operate machines), both reinforcements incompatible with
the use of the substance.
Another possibility is that the reduction or interruption occurs due to aversive
events produced by substance consumption. Again, social and nonsocial
environmental events may act as determinants of this behavior. Fights, reduction of
invitations to social occasions, and problems with control agents such as police can
become motivational operations for the reduction of drug use behavior. Once one
understands what types of events can determine “desire,” it is necessary to understand
what events are the determinants of the failure of attempts to interrupt or reduce
substance use.
Unsuccessful efforts to control substance use can be classified as relapse.
According to Álvarez (2007), relapse is defined as a return to substance use. The
understanding of the behavior of returning to substance ingestion involves reflex
and operative processes. Usually, the reflexes have been attributed to the explanation
of the fissure (aversive conditioned respondents, known as conditioned abstinence),
and to the operant, the relapse (self-administration behavior of drugs). In this sense
a respondent–operant interaction helps to understand the role of the crack in the
unsuccessful effort to control use.
Among the reflex phenomena that help in the understanding of relapse are spon-
taneous recovery, resurgence, reinstatement, and renewal (Bouton, 2002). In the
case of reflexes, the recovery of the value of CS after reflex extinction is investi-
gated. In the case of the operant, there are the phenomena of (1) induction, in which
after extinction, free reinforcements are released, promoting the return of the oper-
ant response; (2) reestablishment, recurrence of extinct operant responses if previ-
ous stimuli or stressing events are reappeared after extinction; and (3) resurgence,
characterized by the reappearance of previously extinct operant responses when
another operant response is put into extinction (Epstein et al., 2006). The interaction
between reflexes and operants helps to understand how the resumption of a CS can
lead to the recovery of operant responses.
For example, in a therapeutic group one client was asked to speak or imagine
drugs without the effects of consumption being present, reflex extinction was in
effect. After therapeutic follow-up the client stopped consuming alcohol and
engaged in a stable love relationship. However, after several fights, the client and his
girlfriend broke up the relationship. The weekend after the end the client went with
friends to a nightclub. After frustrated attempts to start conversations with girls, the
client reported a need to consume alcohol. After consumption, the client felt relaxed
3 Criteria for Substance Use Disorders Diagnosis (SUD): An Behavioral-Analytic… 33

and was able to interact with other people. To the client’s misfortune, consumption
was not restricted to the nightclub and, 15 days later, he returned to consume alcohol
daily, about eight cans a day. This example illustrates a case of resurgence. Besides
the recovery of functioning responses, the use of alcohol can reestablish the value
of other environmental events (smell of alcohol, friends, or nightclub) such as CS.
Other operative processes are also responsible for the “persistence” of drug use.
In this scenario, the concept of stimulus equivalence can also help to understand the
persistence/recurring use of the substance (Albuquerque & Melo, 2005). Equivalence
of stimuli is characterized by situations in which one class of stimuli causes
responses evoked by another class of stimuli (Pierce & Cheney, 2008). DeGrandpre
et al. (1992) demonstrate how events not directly related to substance use can
acquire, through stimulus equivalence, the ability to evoke drug consumption
behavior. For example, the use of drugs correlated to a specific friend is sufficient
for the mere presence of the friend to elicit the compensatory responses typical of
the substance. If this same friend is also correlated to a location, such as a bar, it is
possible that exposure to the bar elicits compensatory responses even if the bar–
drug correlation has never occurred. Thus, even after the interruption of consumption,
if the user returns to the bar correlated to the friend, when arriving at the place he
may experience sensations typical of the abstinence syndrome, which can lead to
lapse and relapse.
The interaction between reflexes and operants can be interpreted in two ways: (a)
as a behavioral chain, where reflex responses (the crack) function as Sd’s that evoke
operant responses (relapse) that remove it from the environment (negative
reinforcement), or (b) as a motivational operation, where the crack functions as a
transitive conditioned motivating operation. The above-mentioned behavioral and
operative response processes, as well as their interaction, contribute to the elucidation
of both the “persistent desire,” the “need to use the drug“ (i.e., crack), and the
“unsuccessful efforts to control substance use” (i.e., relapse). At the same time, self-­
control studies can also help to understand the return to consumption. For this
reason, the behavior of choices and self-control will be presented together in the
next diagnostic criterion.
Criteria 3, 5, and 7: (3) Much time is spent in activities necessary to obtain the
substance, use it, or recover from its effects; (5) Recurrent use of the
substance resulting in failure to meet important obligations at work, school,
or home; and (7) Important social, occupational, or recreational activities
are abandoned or reduced because of substance use.
DeGrandpre and Bickel (1993) point out that substance dependence refers to a
process in which there is a proportional increase in the individual’s demand behavior
and self-administration of drugs, to the detriment of other behaviors that are not
related to the consumption of the substance. Thus, it is possible to state that the
above criteria involve situations characterized by choices.
It is in this sense that the criteria complement each other, since the functional
class outlined above is that the organism stops doing something due to substance
use (criterion 7), spends a lot of time with repertories related to drug use (search,
34 F. H. Baia et al.

acquisition, consumption, and recovery of drug use) (criterion 3), and in fact, this
recurrent use results in failures in daily relationships (criterion 5).
In terms of search, acquisition, consumption, and recovery of use, operating con-
trols and unconditioned respondents are present. The time required for recovery
from the effects of drug use (half-life period) depends on the type of substance, its
dosage, and route of administration. Therefore, in order to understand the recovery
of the effects of the drug, it is necessary to understand physiological aspects and the
mechanisms of action of each substance (pharmacokinetics and pharmacodynamics).
It is not the purpose of this work to discuss the physiological processes of each drug,
therefore we suggest reading Meyer and Quenzer (2005). On the other hand,
operative processes are those that can help in the understanding of the so-called
search, acquisition, and consumption of the substance. And according to the
diagnostic criteria, these behaviors are analyzed in light of the time spent for their
search, acquisition, and use.
As Todorov and Hanna (2005, pp. 159) state, “to choose is the response to one of
two or more accessible stimuli and to prefer to spend more time answering […], or
to respond more to one of them. In this way, the time spent on obtaining and using
drugs is likely to be proportional to their relative reinforcing value. Therefore, the
above-mentioned processes that determine choices allow the interpretation of the
time spent in obtaining and using drugs. Traditionally, the behavioral theory for
choice is the “Law of Equalisation” (Herrnstein, 1970). The general statement of the
law of equalization proclaims that when an organism can repeatedly choose between
at least two different sources of reinforcement (e.g., drugs vs. labor), the proportion
of responses from a given source tends to equal the proportion of reinforcements
obtained from that source. Thus, the proportion of responses in each alternative
(e.g., drugs, work, family, friends) tends to match the frequency, probability,
proportion, magnitude, and immediacy of the reinforcements obtained, and is
further affected by the “quality” of the reinforcement and topography of the required
response (Herrnstein, 1970; Todorov & Hanna, 2005).
For reasons explained by natural selection, organisms have a better chance of
survival when they behave in a way that maximizes the achievement of reinforcements
possible in a situation over time. Authors such as Heyman (1996), characterize
substance dependence as a process in which repeated drug use reduces the
reinforcing value of other activities such as family, work, and friends, in relation to
the activities involving substance use. Czoty et al. (2005) conducted an experiment
in which cocaine user monkeys decreased their drug use due to food. This study
used a choice procedure in which responses to produce cocaine and food competed.
Thus, the study illustrates how therapists can interpret drug use as a choice and
schedule interventions that make other reinforcements capable of controlling the
substance use response. However, the delay of reinforcements can affect these
choices. This will be examined below.
Criteria 6, 9, and 8: (6) Continued use of the substance despite persistent or
recurrent social or interpersonal problems caused or exacerbated by the
effects of its use; (9) Use of the substance is maintained despite awareness of
3 Criteria for Substance Use Disorders Diagnosis (SUD): An Behavioral-Analytic… 35

a persistent or recurrent physical or psychological problem that tends to be

caused or exacerbated by it; and (8) Recurrent use of the substance in
situations where it presents a danger to physical integrity
A particular situation of choice occurs when competing response alternatives
produce different reinforcements—quantitatively or qualitatively. Thus, an “A”
alternative could bring reinforcement of lesser and immediate magnitude, while a
“B” alternative could bring reinforcement of greater magnitude, but delayed. This
competing contingency of choice establishes a particular type of “conflict,” and the
choice of immediate alternatives of lesser magnitude has been called “impulsive
choice,” as opposed to its counterpart, which is called “self-contained choice.”
To some degree drug use fits this description, where the immediate pleasure (or
relief from abstinence) caused by substance use is preferred to maintaining health
and good family and social relationships in the long term. Preferring immediate
drug use over other backward reinforcements would be a way to characterize the
impulsive behavior of drug users (Madden et al., 1997), and their perseverance
would bring about the “social, interpersonal, physical, or psychological problems”
described by the diagnostic criterion.
The relationship between the delay and the control produced by the reinforce-
ment of the response is investigated in an area called “delay discount.” Madden
et al. (1997) demonstrated that nonusers of drugs had less subjective devaluation of
the reinforcement value, due to their delay, when compared to opioid users, for the
hypothetical reinforcement “money.” Taking the results of this study as an example
of the criteria, it is possible to understand that despite the long-term gains that could
eventually occur (e.g., physical, psychological, social, or interpersonal health), the
addict’s behavior of choice is more under control of immediate gains (i.e., the effect
provided by the drug) than the laggards. More than that, when the choice is for the
drug itself, this choice becomes even more impulsive (predilection for the immediate
drug). This model would explain, at least in part, both the continued use of the
substance in spite of problems derived from the use, and the exacerbation of
impulsiveness that starts to be caused by the use.
Still taking as an example the impulsivity/self-control paradigm, the counterpart
of this logic is taken when analyzing the moment of choice for reinforcement of
greater or lesser magnitude. Imagine the individual who has just recovered from a
hangover by proposing abstinence from the drug (i.e., has just quenched it). The
reinforcement of greater and later magnitude (e.g., family, health, and work)
presents a greater subjective value when compared to that of lesser and immediate
magnitude (e.g., alcohol; after all, he has just quenched himself of alcohol). As time
passes and moments approach when the drug is available (e.g., beginning of next
month and receipt of salary), its subjective value increases to the point of exceeding
the subjective value of the once preferred delayed consequences (Madden et al.,
1997; Tucker, 2004). In summary, even if the individual considers his family, health,
and employment more important, when drug availability is signaled (e.g., receipt of
wage, happy hour from work), its value suddenly becomes higher because it is
immediately available (Tucker, 2004). According to Tucker (2004), the consequences
36 F. H. Baia et al.

of remaining abstemious only occur after a very extended period of time (delay of
reinforcement), so that the value of choosing the immediate alternative is higher.
Given this reversal of preference, the predilection for the substance continues
despite the problems caused by its use. Despite the individual having serious health
problems, and/or social problems with his family and at work, and despite the
subject’s awareness of his problems or the risks he faces in obtaining the drug, the
use of the substance persists. This can cause a further aggravation in social or health
problems, which would virtually amount to further delaying the recovery from these
aggravations. Once this delay becomes even greater, the greater will be the tendency
for the individual to make impulsive choices when these immediate reinforcements
are available, as in a kind of vicious circle.
Criterion 10: Tolerance
Tolerance is characterized in two ways: (a) it involves the necessity of larger
doses to obtain the effect previously produced by uses of smaller doses of substances,
and (b) the marked reduction of the effect with the continued use of the same amount
of substance. Both can be understood as fruits of the same behavioral process.
Benvenuti (2004) highlights that through studies on reflex conditioning it has
become more feasible to understand the mechanisms underlying the phenomena of
development of behavioral tolerance. Rescorla (1988) describes that the determining
factor for changing the function of a neutral stimulus (NS) in a CS is the contingent
relationship between US and NS, that is, how much the CS predicts the occurrence
of US. Siegel (1976) conducted an experiment that suggests that the use of a
substance elicits compensatory (metabolic) responses that are opposed to the effect
of the drug. When environmental events are contingent on the drug, such responses
are controlled by the environment, even before the use of the substance. Thus, the
compensatory responses (SRs) decrease the effects of the substance, generating the
aforementioned behavioral tolerance. This is only reversed with the increase in the
dosage of the drug. The understanding of the mechanisms that generate tolerance
syndrome helps to understand abstinence syndrome.
Criterion 11: Abstinence
Abstinence syndrome is characterized by symptoms produced by the decrease of
the substance in the body, either by its suspension or its metabolism. The symptoms
produced are specific to each substance. As described above the reflex conditioning
explains the tolerance. Thus environmental events elicit compensatory responses
even before the ingestion of the drug. In fact the individual experiences symptoms
caused by the suspension of drug use. Thus, the understanding of reflex conditioning
helps to determine how environmental events can act as CS that elicit CR (such as
tearing, hand shaking, headaches) that are characterized as withdrawal symptoms.
O’Brien (1976) conducted an experiment that suggests that the conditioning
reflex of abstinence also helps to understand situations in which the individual
consumes the substance in order to eliminate or relieve symptoms of abstinence.
The environmental CS elicited by CS characteristic of abstinence symptoms, as a
rule, it has aversive components. In this case, operant responses that result in the
3 Criteria for Substance Use Disorders Diagnosis (SUD): An Behavioral-Analytic… 37

suspension of these symptoms may occur. Using substances that produce attenuation
or suspension of symptoms (aversive stimulation) are classified as operating
behaviors maintained by negative reinforcement. If such interoceptive stimulation
(abstinence) is aversive, the behavior of using drugs will be maintained by reducing/
eliminating the symptoms.

Final Considerations

This work presented possible functional interpretations of diagnostic criteria for sub-
stance dependence (i.e. substance use disorders), with the clarity that these are some
possible alternatives, and that the interpretations provided here do not exhaust the sub-
ject. The elucidation of these elementary processes can be a first step towards the
understanding of other more complex processes that involve interaction between some
of the above-mentioned processes. We reiterate that these analyses do not exhaust the
subject, but can contribute to other functional analyses of drug–behavior interactions.
It is also worth mentioning that the agglutination of criteria and the behavioral
phenomena and processes suggested for their understanding has a didactic character.
Therefore, the reader should not take a given situation as watertight. For example,
variables that affect choices may be influenced by other phenomena such as
reinstatement. In this case, the renewal of a stimulus such as CS can alter the
subjective value of the drug. In any case, it is expected that the text has made clear
the importance in recognizing analyses that involve respondent-operating
interactions and/or that encompass biological factors.

Acknowledgments The authors thank Fundação de Amparo à Pesquisa do Estado de Goiás

(FAPEG) for funding the research from which this product came (edital 06/2012, process n°
201210267001219).

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Chapter 4
Basic Concepts of Behavioral
Pharmacology

Fábio Leyser Gonçalves

Introduction

The relationship between human beings and various psychoactive substances has
been the object of curiosity and study throughout much of history. Magic elixirs,
substances used in rituals or recreational drugs such as alcohol have been used by
several people throughout history (Escohotado, 1995). The phenomenon of sub-
stance dependence, although it began to be systematically described in the mid-­
nineteenth century (Hancock & McKim, 2012) had a great advance with the
development of research methods developed by the Experimental Analysis of
Behavior (EAB). It was during the 1950s that the use of these methods, together
with the methods of pharmacology, gave rise to behavioral pharmacology (Barrett,
2002, 2006, 2008; Hancock & McKim, 2012). The birth of this new area of knowl-
edge made it possible to study the interaction between the effect of substances, such
as drugs of abuse and the effects of environmental contingencies. This chapter
intends to present some of the concepts and methods, besides the contributions of
behavioral pharmacology to the understanding of the dependence phenomenon.
Behavioral pharmacology arises mainly from the work of Peter Dews, Roger
T. Kelleher, and William H. Morse in the Harvard Medical School Laboratory of
Psychology throughout the 1950s (Barrett, 2002). At the same time, pharmacolo-
gists and neurophysiologists were beginning to change the conception that commu-
nication in the central nervous system was chemical, and not electrical, as was
thought until then (Valenstein, 2002). Psychiatric drugs such as the antipsychotic
chlorpromazine and the benzodiazepine anxiolytics came on the market and began

F. L. Gonçalves ()
Universidade Estadual Paulista (UNESP), Bauru, SP, Brazil
Programa de Pós-graduação em Neurociências e Comportamento, Instituto de Psicologia da
Universidade de São Paulo (USP), São Paulo, SP, Brazil
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 39

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_4
40 F. L. Gonçalves

to be used clinically (Barrett, 2002). The combination of all these factors made
behavioral pharmacology an extremely fertile area, contributing both to the advance-
ment of what is now called neuroscience and to the improvement and refinement of
methods and concepts of Experimental Analysis of Behavior (Branch, 2006).

Basic Concepts of Pharmacology

In order for a substance to have an effect on an organism, the first step is to be absorbed
by the organism through one of the routes of administration. Each route of administra-
tion corresponds to the place or tissue where the drug will be received. When one
thinks of medicines, the most remembered are the oral route and the parenteral routes
(injections). Some medications are well absorbed by the digestive system and therefore
the oral route seems a good option. Others need quick action and then administration
directly into the circulatory system (intravenous route) may be more indicated. Another
route associated with rapid absorption, widely used by dependents, is the pulmonary
route, in which the substance is transformed into its gaseous state and enters the blood-
stream through the mechanism of gas exchange associated with breathing, as in the
case of tobacco, in the form of cigarettes. The various routes of administration are
related to different absorption processes, i.e., the process of passage of the substance
from the tissue into the bloodstream. The absorption is affected both by the chemical
properties of the substance and by the properties of the tissues in which it is administered.
Once the substance enters the bloodstream, it will be distributed throughout the
body. Once again, its physical-chemical properties will determine in which organs this
substance will act. While liposoluble substances (i.e., those that dissolve in fat) will
tend to remain in organs and fat tissue, water-soluble substances will spread more eas-
ily into the bloodstream. Also, depending on the size of the molecule, it may be con-
fined to blood vessels and not reach some organs. This is the case of our central nervous
system (CNS) where the blood vessels are covered by other cells and only smaller
molecules can penetrate this organ (this protection is called the blood-brain barrier).
After distribution, it is necessary to understand that a good part of these substances will
be metabolized and/or excreted. While metabolization concerns the chemical transfor-
mation of the substance into smaller or easier to eliminate molecules (the main organ
involved in this process is the liver), excretion concerns the elimination of the sub-
stance or its metabolites (products of metabolization) through feces, urine, or even
through the pores on the skin, as is the case with volatile substances such as alcohol.

Neurotransmission

In the case of substances that affect behavior, a limiting step is the arrival to the
CNS, crossing the blood-brain barrier. Although many of the drugs that act in the
CNS also have some peripheral activity, the main effect on behavior is through
4 Basic Concepts of Behavioral Pharmacology 41

central action. To understand how they work, it is fundamental to understand the

functioning of the neurotransmission process. The CNS is formed by billions of
cells, the neurons being the best known. Neurons are cells that function as central
communication centers, all the activity of the CNS could be summarized, in a very
simplified way, to the mediation between the activities of neurons that are in contact
with the environment and the neurons that guide activities of effector organs. This
mediation is done through communication between neurons. This communication
becomes quite complex, since one neuron can communicate with several others, just
as it can receive communication from several others. Initially, the main hypothesis
is that this communication was made through the electrical transmission of nervous
impulses, but as seen above, today it is widely known that most communication
takes place through chemical substances, called neurotransmitters (Valenstein,
2002). These substances, synthesized inside the neurons, are released, and will con-
nect to specific receptors in other neurons (and, even, in the neuron that released it).
The neuron that releases the neurotransmitter is called pre-synaptic, the one that
receives is called postsynaptic, and the place where there is proximity between the
neurons is called synapse. Most drugs that act on the CNS will somehow affect the
neurotransmission process. There are substances that facilitate the process of release
of the neurotransmitter, increasing its availability in the synaptic cleft and therefore
its effect. There are substances that bind directly to the receptors. Those that pro-
duce a similar effect to the neurotransmitter are given the name agonists, those that
bind but do not produce an effect, preventing the neurotransmitter from acting, are
called antagonists. Other drugs can increase the availability of the neurotransmitter
preventing them from being recaptured by the neuron through the inhibition of the
process known as reuptake. Other processes may be affected, but are outside the
scope of this chapter.

Some Methods of Behavioral Pharmacology

The first studies in the area of behavioral pharmacology sought to investigate the
effect of drugs such as pentobarbital (commonly referred to as a sedative) or
d-amphetamine (a psychomotor stimulant) on the performance of pigeons in differ-
ent reinforcement schedules (Barrett, 2002, 2006; Dews, 1955, 1958). With these
experiments, Dews demonstrated that the depressant or stimulant effect depends on
the reinforcement schedule used. While pentobarbital reduced responses in a Fixed
Interval schedule (FI, where the reinforcement becomes available after a time inter-
val), it increased the response rate in a Fixed Ratio schedule (FR, where the rein-
forcement availability depends on the number of responses), d-amphetamine
produced the opposite effect, decreasing the rate in FR and increasing in FI. This
effect became known as rate dependence, since, depending on the initial response
rate, the effect is different (Barrett, 2002; Dews, 1955, 1958; Quisenberry et al.,
2016). This discovery has several implications for both pharmacology and EAB. If,
on the one hand, pharmacologists are faced with the fact that in order to study an
42 F. L. Gonçalves

effect of a substance on behavior, it is necessary to know more about the relations

of the organism with its environment, on the other hand, behavior analysts have to
consider that drug interferences, or other interferences on the organism, can alter the
relationship that the organism establishes with the environment (Branch, 2006).
Still in this early period of behavioral pharmacology, some studies began to
demonstrate that laboratory animals issued operant responses whose consequence
was the administration of a series of drugs related to abuse and addiction, such as
morphine (Thompson & Schuster, 1964), for example. The discovery that drugs
such as morphine, cocaine, and alcohol could act as reinforcers in animal experi-
ments led to a great leap in the knowledge of the dependence phenomenon
(Hancock & McKim, 2012). Initially seen as an exclusively human phenomenon,
the development of self-administration procedures for drugs in nonhuman ani-
mals allowed the advancement of knowledge of brain regions, neurotransmitters
and receptors involved in this process. Furthermore, this laboratory demonstration
helps us reject the idea that substance dependence is an eminently moral problem.
From a behavioral point of view, self-administration procedures have also allowed
the evolution and refinement of concepts and methods for understanding the
dependence phenomenon. A basic implication is that these substances can func-
tion as positive reinforcement stimuli and, therefore, behaviors related to self-
administration can be understood from the operant paradigm (Gonçalves & Silva,
1999; Silva et al., 2001). The basic procedure corresponds to what is usually
called a continuous reinforcement schedule (CRF), which simply indicates that
each emitted response is followed by intravenous or oral administration of a dose
of the drug under study. A peculiarity of this procedure is that, since the effect of
the drugs studied has a varied duration, the simple comparison of the response
rate does not inform about its reinforcement value, not least because some seda-
tive substances, for example, may prevent the emission of the response (Panlilio
& Goldberg, 2007). Other reinforcement schedules have also been used as fixed
and variable ratio and fixed and variable interval schedules. A particularly com-
mon schedule is progressive ratio. In this schedule, the number of responses
required to release the drug dose is gradually increased until the animal stops
responding. This type of procedure allows us to evaluate the effectiveness of the
drug as a reinforcer by comparing the maximum ratio of responses emitted
(Panlilio & Goldberg, 2007).
Second-order schedules have also proved quite useful. In this type of schedule
the response is reinforced by presenting a conditioned reinforcer stimulus according
to a reinforcement schedule, and eventually, following a second schedule, this stim-
ulus is followed by the presentation of the drug. This schedule has a great advantage
by reducing the dose of the drug administered, and also by simulating search behav-
iors for the drug, which can be reinforced by other stimuli such as the behavior of
asking for money. In addition, it demonstrates the possibility of forming condi-
tioned reinforcers, having the administration/effect of the drug as a primary rein-
forcer (Hancock & McKim, 2012). This principle is also used in other procedures
such as conditioned place preference (Gonçalves & Silva, 1999). The conditioned
place preference procedure consists of placing the animal in a box divided into two
4 Basic Concepts of Behavioral Pharmacology 43

sides, identified by different visual and tactile patterns, and assessing whether it is
preferred (stays longer) on either side. Afterwards, the animal receives the drug
administration and is confined to the less preferred side. The final evaluation is the
same as the initial one and, if there is more preference on the side paired with the
drug, it is understood that the drug has a potential for abuse, because it can act as a
reinforcement stimulus (Gonçalves & Silva, 1999).
From the study of the reinforcement function, more complex experiments
began to be performed, using concurrent schedules. The proposition of the
Matching Law by Richard Hernstein (Garcia-Mijares & Silva, 1999; Herrnstein,
1961) allowed, from this type of arrangement, to analyze the distribution of
behavior by several sources of reinforcement. Hernstein’s proposal is that the
distribution of an organism’s activities is proportional to the distribution of rein-
forcement, that is, where there is more reinforcement, more behavior is emitted,
where there is less reinforcement, less behavior is emitted, or, in other words, less
is chosen. In behavioral pharmacology, this type of study allowed the analysis of
competition between drugs and other reinforcers. This allows us to evaluate that,
for example, the same drug can control different response rates depending on
alternative reinforcers, indicating that the reinforcer value of drugs (as well as
other stimuli) is always relative to other present reinforcers (Gonçalves & Silva,
1999; Silva et al., 2001). Thus, if a drug is available in an environment as one of
several options, the reinforcer value will be lower than if there is only one other
option. These research raise the question that, besides identifying the neurobio-
logical, or even behavioral function of a drug, it is necessary to consider the con-
text in which the relationship is established.
Some behavioral theories related to drug addiction are based on the relativity of
the value of reinforcement and can be called choice-based theories (Garcia-Mijares
& Silva, 2006; Heyman, 2018). It is important to note that the term “choice,” as
understood here, is not related to free will or a supposed decision-making process,
but to the distribution of behaviors among various alternatives (Garcia-Mijares &
Silva, 1999). An analysis of the distribution of drug-related behaviors has also ben-
efited from a frontier field known as behavioral economics (Bickel et al., 1993). In
particular, the use of demand curves, i.e., the variation of behavior as a function of
response cost (or price, in economic language), helps to understand, for example,
the effect of public policies such as surcharges on the consumption of alcohol,
tobacco, or even soft drinks and food (Epstein et al., 2012).

Understanding the Relationship Between Drugs and Behavior

As already mentioned, the studies in behavioral pharmacology also require extended

analyses, both from a pharmacological and behavioral point of view. While the
chemical structure of drugs and their neurobiological effects are not sufficient to
predict their behavioral effects, the contingencies alone do not allow the prediction
of behavior, without considering the effects of the drug. Thus, behavioral
44 F. L. Gonçalves

Fig. 4.1 Proposal of integration of the relations among drugs, organism, and environment

pharmacology brings an integrated point of view, in which it is necessary to take

into account the environment in interaction with the alterations of the organism
caused by the drug. Figure 4.1 presents a proposal of how it is possible to integrate
this knowledge. One can understand behavior as the interaction between an organ-
ism and the environment, represented by the bidirectional arrow on the left (identi-
fied by 1). A first extension brought by behavioral pharmacology is that drugs, as
part of this environment, can interact with the organism (2), exerting several stimu-
lus functions such as reinforcement stimulus, conditioned stimulus, and discrimina-
tory stimulus (Leonardi & Bravin, 2012). Finally, it is necessary to consider that the
effect of the drug on the organism, represented by the lower arrow (3), modifies the
functioning of that organism, also altering the way it interacts with the environment
in general, or with the drug itself, in particular. This last point, although not obvious,
was already present in the first studies of the effect of drugs on reinforcement sched-
ules (Dews, 1955, 1958), since the same organism behaves differently under the
same contingency when under different drugs. Thus, beyond an analysis of the stim-
ulus functions, it is necessary to understand how the changes made by the drug in
the organism alter its responses to the environment.

Behavioral Pharmacology of Some Addiction-Related Drugs

This section presents some information on the main substances related to depen-
dence in Brazil. The information is based on the book Drugs and Behavior: An
Introduction to Behavioral Pharmacology (Hancock & McKim, 2012), but it is con-
sidered useful to present this information in a summarized and prominent way, to
facilitate the reader’s access to the area. Information from other sources will be
indicated throughout the text.
4 Basic Concepts of Behavioral Pharmacology 45

Ethanol

Ethanol, better known as alcohol, is one of the most widely used psychoactive sub-
stances in the world. It is normally administered orally and is absorbed by the diges-
tive system and distributed equally throughout the body. Most alcohol is metabolized
by the liver, but it is important to note that during the process an intermediate metab-
olite with toxic effects (called acetaldehyde) is produced, which helps to understand
some effects of acute intoxication. Disulfiram is a substance that inhibits the enzyme
responsible for metabolizing acetaldehyde, and has been widely used in the treat-
ment of alcohol dependence, as it leads to a feeling of unease due to the accumula-
tion of acetaldehyde. Alcohol acts on several neurotransmitter systems, but the main
ones are the gabaergic systems (which involves gamma-aminobutyric acid, GABA)
and glutamatergic (which involves the neurotransmitter glutamate). While GABA is
the main inhibitory neurotransmitter, glutamate is the main excitatory neurotrans-
mitter. The actions on these neurotransmitters are, in a way, complementary, since
there is an increase in the gabaergic system and a decrease in the glutamate system’s
effect, causing, in general, a decrease in activity in the CNS, which can lead to coma
or respiratory arrest, when ingested in excessive doses.
The general effects of alcohol are well known, but it is important to highlight
some. The body develops tolerance to alcohol, i.e., decrease of its effect over the
time of exposure. One of the mechanisms of tolerance is the increased production of
enzymes responsible for metabolism, but there is evidence of behavioral mecha-
nisms, also involved. Abstinence from alcohol is a condition that requires care and
can be characterized by milder symptoms such as agitation and tremors, in an initial
phase, and more severe symptoms such as hallucinations (usually with small ani-
mals or insects) and convulsions. The use of medication to control the symptoms
may be necessary.
Ethanol can act as a discriminative stimulus and can therefore guide specific
behaviors. Furthermore, it is self-administered by animals, acting as a positive rein-
forcer stimulus. With respect to interference in other behaviors, in low doses it
increases the response rate in schedules such as FR and FI. In high doses, the
response rate usually drops, evidencing its sedative effect. Another important effect
is the increase in the frequency of punished behaviors and the decrease in the fre-
quency of negatively reinforced behaviors (Galizio et al., 1984), changes that are
usually called disinhibition and may be related to the increase in aggressive behav-
ior, for example.

Tobacco

Tobacco originated in the American continent and its main component is nicotine.
It is self-generated mainly by inhaling smoke from combustion as in cigarettes
and cigars. This mode of administration is very efficient because the absorption
46 F. L. Gonçalves

occurs quickly through the lung, leading to a rapid increase in the amount of nico-
tine in the blood. Other modes of administration, such as transdermal adhesives,
lead to slower and longer absorption, which has been used in the treatment of
addiction. In addition, nicotine is also absorbed through the mucosa of the mouth,
even in people who do not “bring in” smoke. Nicotine is metabolized by the liver
and excreted by feces and by urine. The main neurotransmitter involved in the
effect of nicotine is acetylcholine, a neurotransmitter involved in learning pro-
cesses and the reinforcement process, for example. This is a neurotransmitter
present in the CNS, and also in the peripheral nervous system, where, among
other functions, it is present in the junction between nerves and skeletal muscles.
When administered in low doses, nicotine works as an acetylcholine receptor ago-
nist (called nicotinic receptors), exerting a stimulating effect. On the other hand,
in high doses, these receptors become blocked, leading to an increase in the num-
ber of receptors in the long term.
In general, nicotine has vasoconstrictor effects, an appetite suppressing effect
and an increased alert state. It also has some effect similar to antidepressants. Some
effects develop rapid tolerance, such as the effects of nausea. Nicotine is self-­
administered by animals, presenting a reinforcer function. Moreover, nicotine seems
to be quite efficient in the formation of conditioned reinforcers that play as impor-
tant a role as nicotine in the process of maintaining self-administration. Nicotine
can also act as a discriminative stimulus. In high doses, nicotine also acts as a puni-
tive stimulus.
With respect to other behaviors, nicotine shows a rate-dependent effect on behav-
iors controlled by positive or negative reinforcement schedules, similar to what
occurs with stimulants such as amphetamines. However, it hinders performance in
DRL (differential reinforcement of low rates), a schedule where the response is rein-
forced after a period without response emission. This data appears after chronic
administration and can be understood as a difficulty to stop emitting behaviors.
Nicotine also facilitates the acquisition of delayed conditional discrimination in ani-
mals, in addition to other procedures that seek to evaluate cognitive functions such
as memory1.

Cocaine

Cocaine is extracted from the leaves of a bush called coca (Erythroxylum coca),
native to the high regions of South America. The coca leaves were used by pre-­
Columbian people and are used in their chewed form until today. The active sub-
stance, cocaine, was only isolated in the middle of the nineteenth century and
banned in the early twentieth century. Cocaine has a stimulating effect and is

1
The term memory is used in its common sense, as the scope of the chapter does not allow a more
detailed discussion of the term.
4 Basic Concepts of Behavioral Pharmacology 47

usually administered via the nose, where it is absorbed by the mucous membrane,
intravenously or by inhalation of smoke, in the form of crack. Crack is nothing more
than crystal cocaine, after association with sodium bicarbonate. The main differ-
ence between cocaine powder and crack is that the inhalation of smoke promotes a
faster absorption, leading to a rapid increase of the drug in the bloodstream, making
its effect more immediate, but more ephemeral. The excretion of cocaine occurs
quickly, taking between 45 and 75 min to eliminate half of the dose (concept known
as half-life). Cocaine acts mainly by inhibiting the reuptake of three neurotransmit-
ters: dopamine; noradrenaline, and serotonin. Dopamine is the main neurotransmit-
ter associated with the reinforcement process and motor control. Noradrenaline is
the main neurotransmitter involved in the processes of attention, wakefulness and
sleep, and eating behavior. Serotonin is a neurotransmitter that acts on aggressive
behavior, mood, and appetite, for example.
The main peripheral effects of cocaine are an increase in heart rate and blood
pressure, in addition to its local anesthetic effect. Cocaine also increases waking
hours and promotes a sense of well-being, increased energy, clarity of thought,
a sense of capacity, and power. It also has an anorexic effect, inhibiting the
appetite and can lead to long-term malnutrition. In high doses it can lead to a
transient psychotic state, with auditory and visual hallucinations and paranoid
delusions.
Although drugs such as cocaine are classified as psychomotor stimulants, it is
important to note that their effect is rate-dependent, as demonstrated by Dews’
(1958) experiments mentioned above. The main functions altered by cocaine are
related to the reinforcement process. Cocaine, like other stimulants, functions as a
reinforcer, and its reinforcer value depends on the immediacy of the effect. This
behavioral principle helps us to understand some of the differences between cocaine
administered by different routes, such as crack and cocaine powder. Cocaine is self-­
administered in animals and its pattern of self-administration is similar to that of
humans, intercalating more intense periods and periods of abstinence.

Final Considerations

In this chapter, the area of behavioral pharmacology was briefly presented. It arises
from the interaction between pharmacology and Experimental Analysis of Behavior.
When two areas meet, they both change and produce a new area. It is hoped that this
chapter will serve as an invitation for some people to venture into this (not so) new
field of study and, above all, will help to understand that the analysis of phenomena
involving drugs and behavior requires a broad understanding and the contribution of
multiple disciplines.
48 F. L. Gonçalves

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Chapter 5
Functional Analysis of Substance
Use and Dependence

Richard Alecsander Reichert, Eduardo José Legal, Simone Martin Oliani,

and Denis Roberto Zamignani

Introduction

When using scientific methods for the analysis of human subjects, one must start
from the assumption that behavior is ordered and determined (Skinner, 1953/2003).
This perspective assumes that the actions of individuals result from processes of
interaction that, once described, make it possible the prediction and, to a certain
extent, the influence over behavior. Circumstances beyond the individual are, there-
fore, relevant—they can and must be identified, described, and managed in order to
promote changes in actions. In other words, behaviors are understood as relation-
ships between the subject (organism) and the environment in which it is inserted,
and not just as actions devoid of history (Abib, 2004)..
Behavior analysis considers that behavior is multidetermined, the result of mul-
tiple functional relationships, in a process of reciprocal determination between envi-
ronmental events and the actions of individuals. Behavioral processes can be

R. A. Reichert ()
Department of Psychobiology, Universidade Federal de São Paulo (UNIFESP),
São Paulo, SP, Brazil
e-mail: [email protected]
E. J. Legal
Universidade do Vale do Itajaí (UNIVALI), Itajaí, SC, Brazil
e-mail: [email protected]
S. M. Oliani
Centro Integrado de Neuropsiquiatria e Psicologia Comportamental (CINP),
Londrina, PR, Brazil
e-mail: [email protected]
D. R. Zamignani
Paradigma – Centro de Ciências e Tecnologia do Comportamento, São Paulo, SP, Brazil
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 51

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_5
52 R. A. Reichert et al.

classified into two categories: (a) respondents or reflexes—involving an organism–

environment relationship in which a response is elicited by a change in part of the
environment (stimulus); and (b) operants—relationships in which one’s actions
operate on the environment, producing changes in that environment (called conse-
quences) that, in turn, modify the likelihood that actions of the same class will occur
on similar occasions, in a bidirectional process (Borloti et al., 2015; Costa &
Marinho, 2002; Moreira & Medeiros, 2018; Nery & Fonseca, 2018)..
Behavior analysis therefore studies the relationships that select and maintain
behaviors that contribute to one’s adaptation and survival in the context. The con-
cept of three-term contingency seeks to explain these relationships, conceptually
representing the factors responsible for the occurrence of certain response classes or
not. Therefore, the relationship between (a) antecedent context, situations which are
present at the time of emitting the response, which, depending on the produced
consequence, set the occasion for the emission of a behavior, is analyzed; (b)
response (action) performed by the organism; and (c) consequent stimuli, which
occur after the response is issued and alter the future likelihood of its occurrence in
similar contexts (Lombard-Platet et al., 2015) (Table 5.1).
Behaviors are multidetermined, that is, there are a lot of relationships and factors
involved that influence them. The causal model of behavior analysis is called the
Consequence Selection Model, according to which any behavior is the result of the
history of interaction between phylogenetic, ontogenetic, and cultural variables
(Skinner, 1987). Substance use, for example, is determined by a complex interplay
of biogenetic and psychosocial factors. To understand these patterns of behavior, it
is necessary to analyze their pragmatic relevance, that is, the role they play in the
lives of individuals. Discovering the functionality of the behavior enables its predic-
tion and control, given that the variables that influence it can be managed (Borloti
et al., 2015; Garcia-Mijares & Silva, 2006; Silva, 2007; Silva et al., 2001; Skinner,
2003; Vandenberghe, 2002).
When talking about problems related to substance use, the identification and
management of the variables involved become essential for formulating the preven-
tion and treatment interventions. To obtain this information, Silvares and Gongora
(1998) suggest a functional analysis of behavior. And the objective of this chapter is
to describe functional analysis as a central tool in the assessment and formulation of
clinical cases related to substance use and dependence.

Table 5.1 Concepts of the three-term contingency

Sd (Discriminative stimulus) R (Response) Sc (Consequent stimuli)
Stimuli present at the time of emitting the Action taken Stimuli produced by the
response; situations in which an action by the response, which alter the
occurs (context). They are also called organism. probability of their emission in
“antecedent stimuli.” similar contexts (Sds).
Source: Lombard-Platet et al. (2015)
5 Functional Analysis of Substance Use and Dependence 53

 unctional Analysis of Behavior and Formulation

F
of Clinical Cases

Functional analysis plays a key role in the formulation of clinical cases and behav-
ioral therapy (Haynes & O’Brien, 1990; Nery & Fonseca, 2018). This process
assesses the environmental aspects and the role that the behavior plays in certain
contexts, or rather, the relationship of interdependency maintained between the
behavior and the environmental variables. More directly, functional analysis is a
way of identifying antecedents and consequences of behavior (Matos, 1999).
To perform a functional analysis is then to identify the function, that is, the sur-
vival value of a given behavior. For that, an analysis must always be contextual-
ized—it is about answering what the function of a given response is for an individual,
or what is the functional relationship between behavior and its immediate and long-­
term effects (Cruz, 2006; Neno, 2003). Regarding the drug use, this process makes
it possible to identify the circumstances (antecedent stimuli) associated with sub-
stance use (response class) and the consequences (consequent stimuli) produced by
these responses (Borloti et al., 2015; Spadin et al., 2018), as shown in Table 5.2.
Psychoactive substances can produce positive and/or negative reinforcers,
increasing the probability of use due to the consequences produced by their
consumption, or later leading to the search for treatment due to the long-term
aversive effects, as exemplified in Table 5.2. Therefore, it is important to iden-
tify the reinforcing (and punishing) elements in the evaluation process. Thus, it
is possible to understand what the relationship with the substance is, what the
predisposing and maintaining factors of use are (peer pressure, interpersonal

Table 5.2 Model of Applied Functional Analysis

Sd (Discriminative stimulus) R (Response) Sc (Consequent stimuli)
Frequently visiting friends who have Giving in to peer Getting rid of peer pressure
the habit of using cocaine. pressure and accepting and/or creating sensations of
using cocaine with Well-being, grandiosity, etc.
friends.
Going through a series of recurring Using alcohol and/or Sensation of relaxation,
personal issues that produce feelings smoking cigarettes getting away from problems,
of discomfort, stress, or anxiety. (tobacco). reducing anxiety, etc.
Being in a music festival. Using ecstasy. Disinhibition, euphoria,
feeling closer to people.
Legend: Notice that the identification of the consequent stimulus (Sc) allows inferring the function
of the response. In the first example, drug use has a dual function: (1) it is an escape-avoidance
response (getting rid of or avoiding pressure from friends) and (2) it provides access to endogenous
reinforcers (feelings associated with well-being, greatness). In the second example, on the other
hand, the behavior of using the drug has also an escape-avoidance role, but of the deprived feelings
of discomfort. Finally, the third example illustrates a relationship in which drug use produces
negative (disinhibition) and positive (euphoria, sense of closeness) reinforcers, both of which are
private. Eventually, an analysis of long-term consequences could indicate punishment, due to
abuse and possible social, occupational, and economic losses
54 R. A. Reichert et al.

conflicts) and what the consequences of this behavior are (social approval,
reduction of symptoms of stress, or anxiety). The 5W’s (Fig. 5.1), being when,
where, why, with, and what happened, are questions to be answered in this pro-
cess. Thus, it becomes possible to develop a plan to modify the contingencies
responsible for the installation and the maintenance of drug use and dependence
and to then teach new behaviors to replace the ones that result in personal and
social losses (Spadin et al., 2018).
For the formulation of the case and in order to understand the relationship one
establishes with the substance, or the function that it plays in one’s life, some
questions are essential, such as: When and how was the last time you used sub-
stances? Where were you? What were you doing? What happened before (in
which situation and what did you feel)? What were the positive and negative con-
sequences of the use? Do you use it alone or with other people? Who do you use
it with? Where is the substance acquired? In addition, it is important to know
one’s family dynamics and professional and financial situation and ascertain the
existence of health problems and psychiatric comorbidities. These questions are
important to identify the variables associated with the installation and mainte-
nance of use (such as social circumstances, for example) and, therefore, plan more
effective interventions, such as the development of assertive coping skills (Spadin
et al., 2018).

Fig. 5.1 5 W’s. (Source:

Based on Spadin et al.,
2018)
WHEN

WHAT WHERE
HAPPENED
FUNCTIONAL
ANALYSIS
5W's

WITH WHY
5 Functional Analysis of Substance Use and Dependence 55

Example of Cases1

V started using drugs as a teenager, at approximately 15 years old. The first use
occurred at the birthday party of one of his schoolmates, where several people who
were part of his daily life were present. At first, V declined the invitation. However,
after several requests and under peer pressure, he could not resist and consumed a
type of alcoholic beverage. Weeks after that, V went to someone’s house to do
school work. In that situation, they again asked him to drink alcohol. To avoid the
same pressure and the embarrassing situation in which he found himself during the
previous social event, he soon accepted the proposal and consumed the substance.
Such behavior became frequent for V in several similar contexts, which illustrates
the concept of social reinforcers (in this case, contingencies of negative social rein-
forcement—the behavior was issued with the function of eliminating aversive social
consequences, such as embarrassment by colleagues). In contingencies involving
social reinforcers, the behavior is maintained by social contingencies—more spe-
cifically, its effect on the behavior of other individuals—such as acceptance, affec-
tion, appreciation, rejection, intimidation, or approval from other people or groups.
In addition to social reinforcement, the behavior of drinking alcohol has acquired
other functions such as relaxing him, favoring social interactions, and creating an
initial excitement (euphoria) (Table 5.3).
W is weekly invited to attend electronic music parties, contexts where the use of
stimulating substances is tolerated, and often reinforced. To stay awake throughout
the party and to facilitate interpersonal interaction, W makes use of ecstasy, a drug
that provides disinhibition, euphoria, and a feeling of being close to other people
(Table 5.4).
So far, the variables present in the current context have been mentioned, from
immediate variables that serve as a “trigger” for using the drug to current variables
that maintain the user’s behavior based on contingencies of positive or negative
reinforcement. However, when analyzing the clinical case, it is also important to
identify what are called distal variables. Those variables that, throughout the indi-
vidual’s life history, contributed to the development of patterns of problematic
behaviors and also of “healthy” behaviors that will favor the process of change.

Table 5.3 Functional analysis of V’s alcohol-consuming behavior

Antecedents Responses Consequences Processes Effects
Birthday party Consuming Peer approval and Positive Initial
alcohol acceptance reinforcement euphoria
Presence of Relaxation
friends
Peer pressure

1
The cases have been analyzed from the formulation model of Nery and Fonseca (2018)
56 R. A. Reichert et al.

Table 5.4 Functional analysis of the ecstasy use behavior in the context of electronic music
parties by W
Antecedents Responses Consequences Processes Effects
Electronic music Using Disinhibition Negative Relaxation
environment ecstasy reinforcement
Presence of friends who Proximity to other Positive Excitement
make use of the substances people reinforcement
Presence of unknown people Interpersonal Euphoria
relationship

History and Development Data

When paying attention to one’s life and development history, we look at variables
such as the parenting practices prevalent in their life history, the history of exposure
to intermittent reinforcement schedules, affective experiences of acceptance or
rejection, history of overprotection or setting boundaries, among others (Banaco
et al., 2012). Such variables play an important role in determining one’s current pat-
terns of interaction with the world.
Parental educational practices are behaviors from caregivers that seek to educate,
socialize, and control their children’s behavior. According to Gomide (2006), posi-
tive educational practices are characterized by positive monitoring, genuine paren-
tal interest in the child with displays of affection and praise; the teaching of moral
behavior, empathy, and self-criticism, through examples from parents and discus-
sions about books, TV programs, among others. Punitive/aversive educational prac-
tices, on the other hand, include neglect—inattention, absence, neglect, omission,
and lack of parental love towards the child—; inconsistent punishment that depends
on the parents’ mood and not on the child’s bad behavior; negative monitoring, with
exaggerated inspection and surveillance by parents in relation to their children; high
frequency of repetitive instructions; relaxed discipline—difficulties in establishing
and enforcing rules; in addition to physical abuse—excessive physical punishment,
usually accompanied by anger on the part of the parents (Rodrigues et al., 2011).
Parental practices influence the child’s development in many ways. Some of these
aspects that may have implications in cases of alcohol abuse or dependence are
highlighted in the text that follows.
In a very summarized way, parenting practices are studied in terms of two basic
dimensions: responsiveness and demand (Ribas et al., 2003). The first dimension is
about the parents’ sensitivity to the child’s demands and their immediacy in meeting
their needs, both biological (food, cleanliness, temperature) and affective and cog-
nitive (interacting verbally with the child, communicating that they believe in the
child’s ability to solve situations of challenge or conflict, to encourage the child to
explore the environment in search of developing autonomy, etc.). Affective and
5 Functional Analysis of Substance Use and Dependence 57

responsive parents contribute to the child acquiring the experience of security when
it comes to affection and trust in interpersonal relationships and in oneself as capa-
ble of producing satisfying social relationships. The second dimension, require-
ment, on the other hand, concerns the actions of parents who set boundaries and
which control their children’s behavior, so that they can be inserted into society,
responding to the rules of social interaction. Demanding parents contribute to the
development of self-control, tolerance to frustration, developing respect for bound-
aries, to the tolerance of waiting in situations where reinforcement is not immediate.
A balanced combination of both factors (authoritative parenting style) results in the
development of the basic repertoires necessary for a healthy interaction with the
world. When either or both of these factors are lacking in parenting practices, there
may be behavioral problems.
Regarding substance abuse, what is called permissive parenting is noteworthy—
permissive parents are very responsive, but not demanding. They are warm and
affectionate, are receptive to children’s wishes, and available to satisfy their needs,
while exercising little authority and limit, not favoring the learning of self-control,
nor the opportunity for the child to exhibit self-management and behaviors of
responsibility, in addition to a low ability of conflict resolution—important require-
ments for the development of autonomy. Permissiveness, when accompanied by
overprotection, also tends to produce low tolerance to discomfort (Maccoby &
Martin, 1983).
Positive parenting practices, in addition to involving the establishment of consis-
tent boundaries, involve, to a greater or lesser extent, a history of exposure to inter-
mittent reinforcement schedules. Contingencies of intermittent reinforcement teach
that in order to achieve some goals, people have to persist and vary when things go
wrong (especially in ratio schedules) or wait for the right time to act (interval sched-
ules). Children who were exposed to moderate and controllable stressors in a grad-
ual and monitored manner, tend to develop the necessary perseverance and variability
to solve problems with autonomy, as well as the necessary tolerance to deal with
situations whose solution is slow, difficult, or even impossible (Banaco et al., 2012).
In adulthood, the combination of a low tolerance for discomfort and low reper-
toire of self-management, self-control and conflict resolution results in a high risk
for the use of tobacco and alcohol (Maccoby & Martin, 1983). When the individual
is faced with difficult or conflicting situations and does not have sufficient skills to
solve them, a condition of discomfort or suffering sets in. As its history also did not
allow the development of tolerance to discomfort, it is necessary to seek something
that relieves suffering - which is experienced as intense and uncontrollable.
Therefore, alcohol plays a role in avoiding discomfort, while postponing the resolu-
tion of the situation.
58 R. A. Reichert et al.

The Developmental Variables Composing a Case Study2

X is 32 years old. His father passed away at 48 due to complications associated with
harmful alcohol use. During childhood and part of teenagehood, X constantly wit-
nessed scenes of domestic violence; his father beat his mother almost daily after
returning from a bar near his home. In addition, X was harassed during the school
years, being the victim of daily bullying among his peers. At the age of 27, he was
diagnosed with depression, due to a history of neglect and physical and emotional
abuse. Concomitantly, he was diagnosed with an alcohol use disorder, claiming that
drinking alcohol would be a strategy to deal with life’s adversities and relieve the
symptoms of anxiety and depression. Currently, X does not undergo medical and
psychological monitoring and continues to make harmful use of alcohol, which
causes him a series of losses in various areas of his life. Among them, the end of his
marriage about a year ago and the loss of his job 5 months ago. These losses inten-
sify the symptoms of anxiety and depression and X uses alcohol to relieve them
(Table 5.5).
Z is 53 years old. In his childhood, he suffered from physical and emotional vio-
lence, which created traumas and led to the decision of leaving home at the age of
14. He is currently on the street, exposed to a series of risks on a daily basis. He is
a crack user, and says that the substance provides an intense state of momentary
pleasure. In addition, to sleep, Z makes heavy use of alcohol, claiming that without
it, he cannot fall asleep due to fear of being raped on the streets (Table 5.6).

Table 5.5 Functional analysis of X’s behavior of using alcohol

History and
development Antecedents Responses Consequences Processes Effects
Alcohol use End of Consuming Easing/avoidance of Negative Relief
in the family marriage alcoholic feelings of reinforcement –
(model) beverages discomfort and Escape and
sadness avoidance
Intrafamily Losing the job Reducing symptoms
violence of anxiety and
depression
Symptoms of Avoidance of
anxiety and beginning tasks with
depression a high response cost
(private (e.g. looking for a
events) job in the face of a
history of alcohol
abuse)

2
The cases were analyzed from the formulation model of Nery and Fonseca (2018).
5 Functional Analysis of Substance Use and Dependence 59

Table 5.6 Functional behavior analysis

History and
Development Antecedents Responses Consequences Processes Effects
Intrafamily Homelessness Using crack Contact with Positive Euphoria
violence other people reinforcement
Childhood Risk of Consuming Reducing the Negative Momentaneous
trauma violence alcoholic state of fear reinforcement self-esteem
beverages and anxiety increase
Other several Falling asleep Relief
risks Relaxation

Final Considerations

As it can be seen in the examples shown above, functional analysis allows us to

understand the relationships that initiate and maintain behaviors, in this particular
case, the use of psychotropic substances. Its clinical relevance is evident in that it
shows how each story implies different variables and how they are of utter impor-
tance in understanding these behaviors, since they signal under which circumstances
the use of a psychotropic substance is more likely. In this way, it shows which vari-
ables control the consumption of these substances.
In addition to being an important instrument for clinical evaluation, functional
behavior analysis allows us to understand the diverse factors that influence drug use
and dependence, breaking from moral models and simplistic views that attribute the
etiology of disorders related to the use of substances only and exclusively to indi-
viduals and their biogenetic characteristics or the pharmacological effects of sub-
stances. Human behavior is multidetermined and, therefore, needs to be analyzed
taking into account its complexity and dynamics. Based on the identification of
variables that precipitate and maintain the behavior, such as substance use, it is pos-
sible to formulate not only individual clinical objectives but also more effective
public policies and prevention and treatment interventions, based on scientific
evidence.

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Chapter 6
Establishing and Abolishing Contingencies
of Crack Use: User Descriptions
of a CAPSad

Eduardo Coelho Abreu and Elizeu Borloti

Introduction

The prevention of the (re)occurrence of risky use of psychoactive substances (SPAs)

during the treatment of this use is of fundamental importance to the objective of the
treatment. This importance is due to the fact that, to paraphrase White (2012), the
(re)occurrence is more than a rule in the process called abuse/dependence of SPAs.
Therefore, understanding the variables that favor or disfavor the maintenance of
treatment gains is a central political, clinical, and scientific issue (p. 5). Thus, this
chapter aims to describe what are the establishing/abandoning contingencies of the
(re)occurrence of crack use in patients at a Center for Psycho-social Alcohol and
Drugs Attention (CAPSad).
Contingencies are relationships of interdependence between drug use behavior
and the environmental context of its (re)occurrence. Recurrence is the repetition of
occurrences of use in a given period of time (Alemi et al., 2004). This indicates how
much people who use drugs “want” the drug and how much they “work” to get it,
that is, how much the use is “motivated” to occur and occur again (Michael, 2000).
The technical term for this process is motivational operation, and can establish or
abolish drug use behavior: establishing operations and behavioral demolishing
operations.
OEs and OAs are events or conditions of stimuli prior to behavior that momen-
tarily change: (a) the value of the consequences that act as specific types of boosters
or punishers; and (b) the probability of evocation of behaviors that were previously
associated with those consequences. As motivational operations (WMs), in the field
of substance dependence, but not only, such events or antecedent conditions exert a

This chapter is part of the first author’s master’s dissertation: Abreu (2015).

E. C. Abreu () · E. Borloti

Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 61

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_6
62 E. C. Abreu and E. Borloti

powerful influence on the use of drugs and other related operating behaviors (e.g.,
calling friends, traveling, etc.) and therefore should be considered in the interven-
tion on use (Langthorn & McGill, 2009). OMs should be envisioned in the analysis
of historical factors that contribute to the understanding of the acquisition and main-
tenance of repertories related to the use of SPAs, indispensable to be functionally
considered, in order to set unique goals in treatment (Dawson et al., 2009; D’Amico
et al., 2009; Dios et al., 2009).
It is clear to see the relevance of WMs in drug dependence intervention from
their two effects (Laraway et al., 2003). In the altering effect of the consequence
value, a StateE establishes the efficacy of a specific type of reinforcement or punish-
ment and a StateE abolishes the efficacy of a specific form of reinforcement or
punishment. In the behavioral altering effect, a StateE evokes behaviors previously
associated with the events it establishes as boosters, and a StateE decreases the fre-
quency or suppresses behaviors associated with events that it abolishes itself as
boosters. An example of these harm-reduction effects of drug use is when a person
avoids using the drug on Sunday because it is important to feel well on Monday in
order to go to work.
With these concepts understood, this chapter sheds light on two of the challenges
related to research on recovery in substance dependence, described by White (2012):
(a) the characteristics of the patient’s life history, family, treatment path, and com-
munity that establish or end the recovery from drug dependence in the long term;
and (b) the strategies used by him to promote the resolution of less-serious problems
in his daily life, without the need for professional intervention. It also intends to
collaborate in the development of better results from drug use treatments, since it
addresses the function of variables prior to use and discusses the difficult task of
maintaining long-term results by preventing recurrence of use (McLellan et al.,
1994; Dennis et al., 2005). This prevention depends on the identification of both
public and private drug use history events (Abreu, 2015).
There are differences of opinion about what the objectives of treatment should be
and what can be evaluated as success or recovery. There is also no single explana-
tion for the (re)occurrence of use during treatment. In the behavioral perspective
characterized here—which defends the need for measurement and prediction
(Alemi et al., 2004)—the description of aspects of the change in the use of SPAs
allows us to anticipate possible (re)occurrences of use (Abreu, 2015). At this point
is the merit of this field research.

Methodology

It is necessary to briefly summarize the methodology used in the study on which this
chapter was based, in order to contextualize how its results were obtained. It was a
descriptive study applied in a natural context, since, without deliberate interference,
it sought to know variables of interest in the occurrences or recurrences of the use
of SPA (its descriptive property) during the treatment of the dependency or abuse of
6 Establishing and Abolishing Contingencies of Crack Use: User Descriptions… 63

SPA (its applied property) in a CAPSad (the natural setting of the study). This
knowledge and understanding of these variables are ultimately aimed, for practical
reasons, at preventing such (re)occurrences. Abreu (2015) found little empirical
explanatory knowledge accumulated on the recurrence of SPAs use in treatment
contexts in CAPSad (it is important to mention that, in behavior analysis, the func-
tional description of a behavioral phenomenon is already its explanation (Baum,
1999). To carry out the study that gave rise to this chapter, approval was required
from the Committee on Ethics in Research with Human Beings (CEP/UFES) and by
the municipal body to which CAPSad is linked.
The survey was conducted with five CAPSad users whose preferred drug is
crack. The exclusion criteria were: (a) having severe psychiatric illness (i.e., schizo-
phrenia or bipolar disorder) not stabilized by medication; (b) having physical dis-
ability not stabilized by medication; (c) being treated involuntarily or compulsorily;
and (d) having another illicit substance used on the same preferential basis as crack.
The inclusion criterion was to be part of the daily care service, a fact that would
ensure the maintenance of the participants in the treatment and, consequently,
access to them for data collection. The inclusion of participants whose preferred
drug is crack is justified in the same criteria of the Borloti, Haydu, and Machado
(2015a) study: (a) the growing prevalence of its use as a preferential SPA among
Brazilians (Carlini et al, (Carlini et al., 2006); (b) its considerable Brazilian con-
sumer market, the largest in the world, which is reaching one million people (United
Nations Office for Drug Control and Crime Prevention, 2010); and (c) the fact that,
in general, these consumers do not believe that this use is a “problem,” a belief that,
also in general, is related to social exclusion, including the exclusion of the users
themselves from public services for treatment (not to mention that the treatments in
these services are usually not adjusted to their demands that, if not met, have as an
outcome the severity and poor prognosis (Brazilian Psychiatry Association, 2012).
The instruments used for data collection were: (a) Multidimensional evaluation
questionnaire, which aimed to evaluate the patient’s reason for seeking treatment,
the patient’s situation in relation to the treatment, the characteristics of their behav-
ior of crack use, their family relationships and other relationships, among other
psychosocial aspects; (b) Inventory of drug use situations (ISCD), composed of 50
items, which provides a profile, on a 4-point Likert scale, of the estimates of the
frequency of use in the last 3 months, questioned about being high-risk situations
(Annis & Martin, 1985; Borloti & Cesar, 2015); and (c) Semi-structured interview,
which complemented the data from other instruments, adding direct verbal reports
of public and private environmental events related to the use during the data collec-
tion period, contemplating avoidance behaviors or strategies for maintaining the
weekly gains of treatment.
After the survey was approved by CEP/UFES (Universidade Federal do Espírito
Santo, Brazil) and the municipal health department, it was discussed with the coor-
dination of CAPSad to define the other questions necessary for it to be carried out,
such as the use of rooms for interviews, the presentation of the survey to the users
of the service and the scheduling of visits by the researcher to the site. Later, inter-
acting with the collective activities of CAPSad, the research was presented to all
64 E. C. Abreu and E. Borloti

patients and for the five of them who showed interest in integrating the research as
participants, meetings were scheduled in which the term of consent was presented
in order to formalize the agreement with the participation, such as ensuring the
confidentiality of personal data provided and the scheduling of interviews.
In the following weeks, six interviews were conducted with each of the five par-
ticipants, which took place between 2 March 2015 and 25 May 2015. In the initial
interview, the multidimensional evaluation and the first ISCD application were
done. Later, every two weeks, the meeting was guided by the semi-structured inter-
view to follow the progress of the patient’s treatment at CAPSad. At the end of
3 months of collection, in the sixth interview, ISCD was applied again for future
comparison with the results of the first application.
The multidimensional evaluation questionnaire has composed a simpler data-
base. The content of its major topics allowed the grouping of participants’ answers
(P1, P2, P3, P4, and P5), indicating idiosyncratic situations of each one’s treatment
processes.
ISCD generated data that compared the usage pattern at the beginning and end of
the collection period. The greater the outcome of a participant, the greater the num-
ber of situations of risk for the use of the drug experienced by him/her. Comparing
the averages of these values in the first and second applications of the instrument, it
was possible to estimate a percentage of recovery during the collection period and
which situations were considered the most problematic (by the highest averages
among all applications of the instrument, for all participants).
The interviews, conducted every two weeks, provided data that made up a data-
base described according to their relevance to the objective of this study, since, as
predicted by the recurrent and chronic characteristics of substance dependence
(White, 2012), not all meetings would provide elaborate verbal reports of changes
in drug-related behavior. The treatment of these reports involved grouping similar
descriptions by the same participant in different weeks, or between different partici-
pants in the same week. In order not to repeat them on a case-by-case basis, they
were grouped and discussed in general and functionally, indicating which partici-
pant explained which response and in which interview. Thus, the discussion was
focused on the dynamics of the process of the most important events and exempli-
fied with the most demonstrative answers of that dynamics.
In the interpretation of data, the theoretical reference was the analytic-­behavioral.
Therefore, this chapter brings a novelty to the field of “relapse prevention,” in which
the most common is to find studies with cognitive-behavioral interpretation (e.g.,
Alan Marlatt et al., 2002; Romanini et al., 2010; Tapert et al., 2004).

Results and Discussion

Table 6.1 summarizes the participants’ profile.

It is important to emphasize that during the collection process, more than serving
its original purpose, the Multidimensional Assessment Questionnaire has acquired
6 Establishing and Abolishing Contingencies of Crack Use: User Descriptions… 65

Table 6.1 Profile of participants

Personal goal in
Sex Age treatment House Health problem
P1 Male 57 Abstinence of use In street situation Hepatitis, Anemia,
Insomnia.
P2 Male 35 Abstinence of use Fixed residence Dependency on alcohol
P3 Male 46 Reduction of damage Shared residence Insomnia
from use (“republic”)
P4 Male 49 Abstinence of use Fixed residence –
P5 Female 31 Abstinence of use Shelter –
Source: Reprinted from Abreu (2015, p. 49)

a function to the treatment. Its application cannot be, and should not have been,
“nonclinical” (Madrid, 2009). The presentation of its items was done with sensitiv-
ity: (a) the ambivalence that usually accompanies the patient during treatment
(Borloti et al., 2015b); and (b) the need to strengthen treatment adherence and par-
ticipation in research. Therefore, it also served to establish a better relationship
between researcher and participant, affecting the reinforcing value of the bond
established between both, necessary for subsequent contacts, already with a thera-
pist–patient relationship aspect. This clinical emphasis on research cautiously looks
at verbal reports collected in questionnaires, inventories, or interviews. As the report
is a perception of behaviors or facts, and not behaviors or facts that have occurred,
its analysis, from the perspective of behavior analysis, always requires its under-
standing in its antecedent and consequent environmental variables (Ferreira de
Mattos Silvares, 2006).
About the reason for the search and current treatment situation, although
everyone described improvement plans, they did not describe problem situa-
tions when asked what motivated them to seek treatment. Rather, they described
how they learned about CAPSad and how far they had come. The most common
source of indication was the referral through the primary health care unit of
their territories, followed by referrals by family members (P3), as well as refer-
rals by the service at the reception center for drug users of the “Rede Abraço,”
Program of Integrated Actions on Drugs of the government of the State of
Espírito Santo at the time (P5).
The majority of the participants considered the use itself as a determining factor
in the state of their lives at the time of the research; and for this reason they intended,
with the treatment, to be able to recover bonds with the family and/or children, and/
or with the old activities of study and work, bonds that they considered “more wor-
thy.” P3, on the other hand, intended only to reduce the damage of use.
All reported motivation in, having progressed in treatment, achieving better liv-
ing conditions and personal goals. The role that CAPSad has for these participants
is from a place where they see themselves distant from the “reality of the streets,”
distant from use, closer to other patients in recovery. Being at CAPSad has been
repeatedly described as being in a place “destined for learning” and which offers
“security” from the different ways of accessing the drug outside.
66 E. C. Abreu and E. Borloti

The substance of preference, the focus of the treatment of all participants, is

crack. The frequency and amount used varies widely among them and, in general,
their reports on “how much” they use merge with others, such as those of the form
of use (the “how”). The responses obtained were “I’m using very little” (P2, P4),
“I’m not using as much as I used before” (P1), “I can’t describe” (P3), and “I always
use as much as I can” (P5). As for the form of use, P1, P2, and P4 said to make use
alone from other people, while P3 only did so occasionally, sometimes making use
with “some companion.” P5, on the other hand, always used in the same place where
he had access to the drug, which normally coincided with the place of prostitution,
exchanging sex directly for crack or for money to buy crack.
As for the family relationship and other relationships, while P3 and P5 were
completely estranged from their children and any other member of their family, P2
and P4 were living with family members and P1 had a good relationship with the
former spouse. The proximity or distance from their families appeared as a variable
that directly influenced the progress of the treatment, since the major supporters of
the treatment were family members, nuclear (P1, P2 and P4) or former spouse (P1).
In the case of P3 and P5, the distance from their families and their children gener-
ated sadness and discouragement, negatively interfering with the treatment. Despite
this, the re-approximation of their loved ones was, according to the reports, an
objective to be achieved as a consequence of the behaviors that define the control of
the use of crack (P3) or the complete interruption of the use of any SPAs (P5).
For those who had family support, family members always ended up acting as
providers of rules to be followed, explaining variables related to keeping away from
the use and the problems it brought. However, the family also emerged as a prob-
lem, as in the case of P1 and P5, who saw the conflicts in it as intensifying the use.
All the participants reported discomfort in the face of their relatives’ distrust of
them, both with the probability of “treatment leakage” and the lack of understand-
ing of the difficulties in avoiding the use of crack.
Everyone could see when the crack craving started to bother, such as generating
uncomfortable body sensations, headache, insomnia, nausea, and the urge to use.
The most common strategies to avoid consumption varied topographies in attempts
to get closer to the family and change the daily routine, seeking to get away from
places and people related to use.
There was a constant complaint that the interests and objectives in the treatment
differed greatly from person to person. Everyone was afraid that differences in goals
and stages in treatment progress would become a problem for their treatment. This
reinforced the elusiveness of the social approach in CAPSad, leading everyone to
consider others (participants and nonparticipants) only as colleagues, not as friends.
As for the recurrence of use, P3 was the one that had more reports about this,
being this recurrent use in motivational events present in daily life, allowing a
greater understanding of the motivational operations of the use of crack and the
motivational function that the instruments of data collection, already as an interven-
tion, began to have on the use throughout the collection. For P3, the use of crack
allowed him to feel relief from the tension of work as a tattooist and from the fatigue
or boredom of everyday life. Several reinforcing consequences were attributed to
6 Establishing and Abolishing Contingencies of Crack Use: User Descriptions… 67

his use behavior, making him assume that his goal in treatment was only to get back
to control the amount used and the frequency of use. His treatment, however, did not
become unfeasible for this reason. In the weeks that followed in data collection, P3
reported building new goals to be achieved, which gradually led him to develop a
verbal repertoire skilled in describing amount and frequency of use. It seems that
the research was interventionist in modifying behavior in relation to these properties
of use, because goals could be set: initially to achieve the reduction to a certain daily
amount and then to a weekly amount. Thus, P3 was able to bring its occurrences of
use under control of quantitative properties that were not the focus of its atten-
tion before.
This change in behavior occurred as P3’s behavior ceased to be under control
reinforcing only the immediate effect of the drug. His behavior became more sensi-
tive to the variables prior to craving. This sensitivity enabled him to anticipate and
avoid situations in which craving would be so intense that use could not be avoided.
The effects of SPA itself have never ceased to have reinforcing value, but P3 seems
to have become more sensitive to the undesirable consequences of possible occur-
rences of use, and thus may choose to make the appropriate decision, either by the
moments or by the places where such decision was discriminated as necessary
(Martin & Pear, 2009).
This same behavioral process can be observed during the collection with P2 and
especially P4. The latter justified that although the immediate effect of SPA use was
desired, the negative effect used to last weeks: the disappointment of the family, the
feeling of failure or the worsening that it felt when the use recurred.
It can also be observed that drug use by the participant with more–frequent-use
reports (P3) and by the one with less-frequent-use reports (P4) occurred, but in a
different behavior pattern. Both started to emit SPAs use behavior in a reduced fre-
quency and intermittent reinforcement (Martin & Pear, 2009). This may have hap-
pened because, although this scheme is more commonly used to develop behavioral
persistence, in some cases it can be used to reduce the frequency of an unwanted
behavior, which, for some reason, has great reinforcing value and, thus, its recurrent
evocation is quite likely. In both cases, the use of crack became something undesir-
able and therefore should be controlled or allowed only at regular intervals or, in the
case of P4, very long, so as to no longer characterize a use with indiscriminate func-
tion, but with a negative reinforcing function (soften the negative bodily effects
caused by long-term abstinence). For P3, this new function of use could be a begin-
ning of the development of its improvement, while for P4 the strategy was progres-
sively, or less and less, to use any substance, so as not to suffer from the uncomfortable
effects of a total and abrupt interruption of use.
Total interruption of use is a strategy of behavior change that was often seen by
patients themselves as the only way to recover a substance dependent, a report
made by P1 during the first interview, by P2 during the second interview and by
P5 during his fifth and last interview. However, this strategy implies some predict-
able problems to any extinction of behavior scheme, to be considered in drug
addiction intervention. Initially it implies an abrupt increase in the frequency of
behaviors aiming at reinforcement no longer presented to the disappearing
68 E. C. Abreu and E. Borloti

behavior; later, a variety of behaviors were evoked in order to try to achieve the
desired reinforcement (Martin & Pear, 2009).
For a substance dependent, this often implies what was reported by P1 during the
fifth interview: his attempt to completely stop using any amount of crack ended up
producing a crisis of abstinence so severe that he acted as an operation that estab-
lished the reinforcing value of unwanted behavior never before issued, in this spe-
cific case, stealing money, punished with one week’s detention. After his release
from jail, the use of SPA occurred again, but in a more moderate way. The episode
was related to the description of the objective of completely interrupting the use,
only in a gradual manner.
The negative punishment scheme can be seen in P5’s accounts, when he described
that he stopped living with his family amidst the fights generated by his use of
crack. Her mother expelled her from her home after recurrent disagreements, mainly
for disagreement with the SPAs use behavior assumed by P5. In a way, this same
kind of disagreement was the reason P2 separated from his wife and had to go back
to live with his mother, and also P1 separated from his wife and went to live on
the street.
On the other hand, positive reinforcement schemes of appropriate behaviors to
increase their frequency were described initially by P2 and P4 (both during the sec-
ond interview), and later by P1 (third interview) and P5 (fourth interview). Whether
it was to improve the relationship with the family and get back in touch with the
children, or to obtain better living conditions, get a good job (P5), or complete their
studies, all, at some point, described reinforcements they intended to achieve. In this
way, they focused on activities other than those of use. Gradually, they promoted the
fading of the reinforcing quality of drugs in their lives as they sought to develop
repertories of behaviors such as visiting family, walking, eating, and caring in order
to produce positive reinforcements, such as the family members present, the good
taste of food, a different place visited, sobriety, or improved physical conditions and
appearance (clean body, without burns, with adequate weight and pleasant aspect).
All participants were able to hear reports on the development of behavioral per-
sistence through an intermittent reinforcement scheme (Martin & Pear, 2009). In
these cases, the persistence placed was to be able to withstand abstinence more and
more as they gradually became aware of better life chances, the further away they
got from risky use of crack. Some aimed at abstinence as the goal of treatment, oth-
ers at harm-reduction, but all, at some point, stressed the importance of persevering
in treatment, developing resistance to the frustration of the absence of the reinforc-
ing effect caused by the drug, compensated by long-term gains.
It is essential to emphasize the demand for attention to variables that precede the
behavior of use that can help both the patient in treatment and the service that serves
them, in order to preserve the advances in patient recovery, avoiding recurrence of
use. There were, in common, in the reports of the participants, descriptions of ante-
cedent events that compose a specific type of variable for momentarily altering the
reinforcing value of the consequence of a certain behavior and, consequently, evok-
ing this behavior (Michael, 1993, 2000). This specific knowledge allows access to
6 Establishing and Abolishing Contingencies of Crack Use: User Descriptions… 69

motivational variables of SPAs use behavior and, thus, describe the probability of
use, providing an essential theoretical tool to prevent its (re)occurrence.
During data collection it was possible to notice frequent descriptions of these
variables in the reports of the participants, as in the description made by P3, that the
substances used by any chemical dependent have some positive effect, otherwise
they would not be used. This fact is undeniable, since SPAs work as unconditioned
boosters. Like food for a hungry person or water for a thirsty person, for a substance
dependent abstinence implies an operation establishing the use of SPAs, increasing
the probability that they will be used the more they are deprived (Martin &
Pear, 2009).
A broad example of establishing operation is drug deprivation combined with
discriminatory stimuli, such as people who are also users or places where the sub-
stance is commonly used. While for P1, P3, and P5 the occurrences of use are
everyday events, either because, at the time of the study, they were living on the
street or in shelters and had constant and inevitable contact with people who use the
most varied drugs, for P2 and P4 the occurrences of use are sporadic events, because
they tried to distance themselves from places and people whose presence, in the
deprivation of the drug, made the emission of the use behavior more likely. For all
participants, the environments of access to the drug, as discriminatory stimuli,
become more powerful when combined with the deprivation of the drug in the
organism as an establishing operation. This knowledge is part of self-control of use,
and can act on the predisposition to frequent environments where they know they
will be more prone to use, also by the presence of people who facilitate access to the
drug. On the other hand, it has been reported that isolation can also serve as an
establishing operation. P2 described a certain situation in which the occurrence of
SPA use occurred because he distanced himself from home, after having spent a
long time thinking about the effects and the substance itself, until he could no longer
control himself in order to avoid use.
When they answered about the reasons why they made occasional use of crack
between the periods of each interview, there were several reports of operations
establishing the use: facing negative emotions (P1 and P5), sadness, or discourage-
ment in everyday life, facing negative physiological states, such as craving provided
by deprivation of the substance, or feelings of anxiety and “nervousness.” P1 and P3
also considered that the use of crack was useful to “escape from reality,” a means to
achieve some momentary relief. On the other hand, P2 and P4’s accounts of opera-
tions that were able to avoid use by staying at home or by surrounding themselves
with people who supported them in their treatment serve as examples of use-­abusing
operations.
Other examples of SPAs can be seen in the P5 report, which describes that the
better you feel, the less will you have to make use of any substance. When asked
what this “feeling better” would be, or what would elicit it, P5 addresses the role
that CAPSad plays for her in her treatment, functioning as a place where all activi-
ties are aimed at reducing as much as possible the likelihood that patients under
treatment will feel the need to use some substance. In this case, the medication
prescribed for the patients also performs the function of an establishing operation.
70 E. C. Abreu and E. Borloti

However, for the vast majority of participants, the operation that demolishes the
most recurrent use is also the most controversial and can even be assessed as con-
tradictory. For many, the only way to diminish the willingness to use some sub-
stance is by making use of some other substance that produces less damage. The
harm-reduction policy contemplates this logic, in this case, replacing a drug such as
crack, which causes extensive harm, with one with less-harmful effect.
The ISCD results shown in Table 6.2 were grouped into total values, adding the
value of all inventory responses in each application, as well as average values
(obtained by dividing the total value by the number of questions). In this way, the
variation of results in percentage can also be calculated: how much each result var-
ied in 3 months. The data in Table 6.2 do not correspond to the intensity or fre-
quency of SPAs use itself, but to the self-assessment of the risk of use by each
participant at the time of ISCD applications. The result of each participant was
analyzed according to the stage of their treatment.
The analysis of the data in Table 6.2 allows one to follow the development of the
treatment, for example, P2 obtained the greatest variation of results, going from a
high total value to one of the lowest, coinciding with its solid change of routine,
being less exposed to situations that would be at great risk of SPAs use. Throughout
the data collection period, he received constant support and attention from his
mother, and even at times when he felt he was closer to losing control, he managed
to stay in the focus of his treatment.
It is noticeable that all the results correspond to values that, in the second appli-
cation, are higher than 50. These values would be equivalent to average 1 in the
answers to the inventory, corresponding to a behavior of complete abstinence from
use, which despite being a goal for some participants, is not required in the work of
CAPSad. They can be considered significant advances in the treatment of P1, P2,
and P4, since the verbal report of their uses suffered a change in a period of 3
months of data collection, and even in the cases of P3 and P5, it is possible to notice
that there were behavioral gains in the treatment. Despite these gains for some and
not all, the probability of use was discriminated from the ISCD. Table 6.3 informs
the previous context that may or could have acted as a motivational operation for
(re)occurrences of crack use.
It is possible to verify in Table 6.3 that out of the 50 risk situations, 9 obtained
mean responses equal to or greater than 3, indicating that these situations are the

Table 6.2 Total score, average, and change in responses at ISCD

1st application 2nd application
Participant Total Average Total Average Variation
P1 134 2.68 107 2.14 −20.15%
P2 123 2.46 73 1.46 −40.65%
P3 131 2.62 132 2.64 0.76%
P4 65 1.3 58 1.16 −10.77%
P5 90 1.8 97 1.94 7.78%
Source: Reproduced from Abreu (2015, p. 64)
6 Establishing and Abolishing Contingencies of Crack Use: User Descriptions… 71

Table 6.3 Items, situations, and categories of situations with higher risk of (re)occurrences of
drug use.
ISCD High-risk situation for (re)use (ISCD Higher average
Item issue) response value High-risk situation category
1 When I got depressed 3 (first Facing negative emotions
application)
4 When I felt I had nowhere to run 3 (first
application)
34 When I was overwhelmed and 3 (second
wanted to escape application)
24 When I felt anxious or tense 3 (both Facing negative
applications) physiological states
16 When I unexpectedly found one of 3.2 (first Surrender to temptations and
these drugs or happened to see application) impulses in the absence of
something that reminded me of these someone else
drugs
21 When I was alone 3 (first
application)
46 When I started thinking about the 3.4 (first
effect of the drug application)
37 When I had conflicts at home 3.2 (first Confronting interpersonal
application) conflict
48 When I was with a group of people 3 (first Social pressure for the
and everyone was using these drugs application) occurrence/recurrence of
psychoactive substance use
Source: ISCD item extracted from Annis, H. M., & Martin, G. (1985). Inventory of Drug-Taking
Situations. Toronto, Canada: Addiction Research Foundation. High-risk situation category
extracted from Borloti & Cesar (in press). Drug relapse prevention strategies. In: Borloti, E., Balbi
Neto, R. de Q. B., Machado, A. R., Andrade, A. da P. Crack, alcohol and other drugs: intervention
strategies for ongoing formation

ones that offer the highest risk of use for the survey participants. These situations
notoriously coincide with the different reports already described as operations
establishing the use of crack: the aversiveness of negative emotions and deprivation
of use, felt as craving in places where crack is used and in the presence of other
people who use it, with a discriminatory function.

Final Considerations

Following CAPSad users in treatment for descriptions of common variables in the

recovery process was a valuable experience. Through sequential interviews and
other tools, new data can be achieved that describe the progress and difficulties
faced during treatment. The results give several indicators of the importance of
maintaining constant attention on the variables that control the behavior of
72 E. C. Abreu and E. Borloti

participants to use drugs, emphasizing the need to access factors of the patient’s
history and motivational operations that influenced the emergence and maintenance
of SPA use.
The constant attention to the control of stimuli and the motivational context of
drug use allows us to predict the probability of both the emergence of (re)occur-
rences of use and the maintenance of the objective of treatment. By having such
attention, behavioral changes may occur, such as those observed in this study. More
than describing and discussing operations that establish and destroy the use of SPAs,
this study described strategies for data collection that ended up contributing to the
recovery process of participants, bringing greater self-knowledge about the vari-
ables that controlled their use behavior. It can be considered an empirical knowl-
edge about the dynamics of treatment in substance dependence.

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 Part II
Clinical and Social Interventions
Chapter 7
Contingency Management
for the Treatment of Substance
Use Disorders

Viviane Simões, Rodolfo Yamauchi, and André Q. C. Miguel

I ntroduction: Substance Use from an Operant

Behavioral Perspective

Most academic areas that study substance use disorders (SUD) understand this phe-
nomenon as a psychiatric disorder, where individuals develop a compulsive and
uncontrolled use of substances, despite the various adverse effects that this con-
sumption brings to themselves, their family and the community (APA, 1994). This
understanding is supported by neurobiological findings that not only describe the
mechanisms of drug action in the brain but also point to the structural and functional
neurological changes caused by the chronic use of these substances (Kalivas et al.,
2005; Volkow et al., 1997, 2000).
It is a consensus that SUD can cause diverse suffering and harm to individuals
and, therefore, it is valid to characterize this behavioral repertoire as the product of
a psychopathology. However, from a behavioral perspective, to understand sub-
stance consumption as pathological behavior is a misconception (Bigelow et al.,
1998). It is understood that addictive behaviors may be considered inappropriate,
undesirable promoters of the most diverse adverse consequences, potentially result-
ing in serious harm to the individual and to society (Higgins & Silverman, 1999).
Nevertheless, such behaviors cannot be considered pathological from an operant
behavior perspective since they follow the same principles and laws of any operant

V. Simões · R. Yamauchi
Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, SP, Brazil
A. Q. C. Miguel ()
Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, SP, Brazil
Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in
Addiction Research, Washington State University, Spokane, WA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 77

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_7
78 V. Simões et al.

behavior. That is, these behaviors are controlled by the functional relationships
between the contingencies present in their environment (Bigelow et al., 1998). In
the same direction, drug abuse can be considered compulsive, if by this we mean a
high frequency of self-administered, but not uncontrolled behavior (Bigelow et al.,
1998; Higgins & Silverman, 1999). On the contrary, it is strongly controlled by the
immediate reinforcers produced by substance use (pharmacological effects), as well
as by other delayed conditioned reinforcers, generally more difficult to observe
(Higgins et al., 2004).
As will be seen below, substance self-administration responses can be consid-
ered as learned normal responses that lie some point along a continuum ranging
from sporadic consumption, with little or no associated harm, to excessive con-
sumption accompanied by numerous undesirable and adverse effects. A substantial
body of studies provide the empirical basis for an operant understanding of SUD
(Higgins & Silverman, 1999; Higgins et al., 2004). According to this perspective,
the behavior of self-administering a substance should be considered the central
problem in individuals with SUD, as this is the only response that is always present
and is mandatory for anyone who closes a diagnosis of SUD (those who do not self-­
administer a substance cannot have the problems resulting from that use). Within
this reasoning, if the environment can be changed in such a way as to reduce or
extinguish substance use, it would most probably also reduce or eliminate the nega-
tive effects (aversive consequences) produced by this response.

 heoretical and Experimental Basis

T
for the Self-­Administration of Substances

Experiments on operant conditioning and behavioral pharmacology were first

developed in the 1950s (Griffiths et al., 1980; Higgins et al., 2004). Initial studies
demonstrated that the same substances abused by humans are spontaneously con-
sumed by several other species (Aigner & Balster, 1978). In fact, without any previ-
ous exposure, will animals voluntarily consume a large amount of psychoactive
substances (Griffiths et al., 1980). Animals also learn new and complex response
that, as consequence, allow them access to the effects of a given substance (Griffiths
et al., 1980). After some exposures, the reinforcing effects contingent to the con-
sumption of these substances become so strong that these animals will give up other
important reinforcers such as water and food in order to have access to these sub-
stances instead (Petry & Heyman, 1995). In summary, these experimental findings
with animal models suggest that (1) for these species, substances of abuse act as
unconditioned positive reinforcers; (2) these reinforcers are so strong that animals
will emit high-cost responses in order to gain access to these substances; and (3)
after some exposure these reinforcers will gain enough strength to compete with
other important reinforcers (such as food and water).
7 Contingency Management for the Treatment of Substance Use Disorders 79

Thus, substance use (self-administration) can be understood as learned operant

behavior (behavior controlled by the consequences it produces) that is initially con-
trolled by the unconditioned reinforcing effects (subjective and physiological
effects) caused by the substance (Cahoon & Cynthia, 1972; Higgins & Petry, 1999).
As with any reinforcer, the effects of the substance will reinforce any response that,
as a consequence, allows access to the substance (in human natural contexts some
examples would be going to the dealer, buying the drug, and using it).
These findings are important, but do not explain the interaction between self-­
administration and other contingencies present in the same environment where it
occurs. It is known that all operating behaviors are sensitive to the presence of other
contingencies in their environment (Skinner, 1969). Thus, the response of consum-
ing substances should also be influenced by the presence of other contingencies.
In fact, experimental studies suggest that other environmental variables not
related to reinforcers contingent to substance use may influence the reinforcing
effects of substance use itself (Higgins & Petry, 1999). Aversive stimuli, such as
shocks, social aggression, social exclusion, or reduced availability of food, liquids,
or exercise, lead to an increase in the frequency of substance use among laboratory
animals (Goeder & Guerin, 1991; Wolffgramm & Heyne, 1995). However, when
animals are exposed to alternative sources of positive reinforcers, not related to
substance use (e.g. access to female, nest building materials, appetizing foods), the
frequency of substance use decreases significantly (Higgins, 1996, 1997).
Data obtained from animal models and clinical studies involving human volun-
teers suggest that humans behave similarly to other species with regard to the con-
sumption of psychoactive substances. Humans learn and maintain new responses to
access drugs, reach high levels of consumption (with risks of overdose), increase the
frequency of use in the presence of aversive stimuli, and decrease this frequency if
positive reinforcers are available in their environment (Higgins, 1997; Higgins &
Petry, 1999). These findings suggest that: (1) the same operant conditioning pro-
cesses present in substance use responses can be observed in several species, includ-
ing humans; (2) as with all operant behaviors, substance use is also sensitive to the
presence of other contingencies present in the environment where consumption
occurs; (3) substance use can increase or decrease depending on possible changes in
contingencies present in a specific environment; and (4) enriching the environment
with other sources of positive reinforcement can promote a reduction in drug use.
As a rule, when an individual begins to use a substance, this consumption is
controlled only by unconditioned positive reinforcers (e.g. effect of the substance)
and conditioned positive reinforcers (e.g. friends of use). As substance use increases
in frequency and becomes more generalized to other environmental contexts, new
contingencies also come to control substance use. Unconditioned negative reinforc-
ers (withdrawal symptoms) as well as conditioned negative reinforcers (aversive
sensations produced by a fight with a friend or the end of a relationship) also come
to control substance use (Higgins, 1997; Higgins & Petry, 1999). In other words, the
reinforcers that control the substance use can be separated into four groups:
80 V. Simões et al.

• Unconditioned positive reinforcers caused by the physiological effects induced

by the substance (e.g. euphoria, relaxation, feeling of transcendence).
• Conditioned positive reinforcers linked to the social environment where con-
sumption occurs (e.g. group of friends, bar table, football game).
• Unconditioned negative reinforcers (e.g. withdrawal, craving).
• Conditioned negative reinforcers linked to aversive aspects of the environment
(e.g. fighting with a family member, loneliness).
Generally, one or more of these reinforcers are present during the initiation of
substance use, and most likely all of these reinforcers are present when the indi-
vidual presents an abusive and/or addictive pattern of substance use.
The more the reinforcing effects linked to substance use (either for pleasure or to
alleviate cracking) are intensified, the greater the amount and frequency of sub-
stance use. During this process, the individual’s repertoire is reduced as the indi-
vidual is increasingly extinguishing responses that lead to other reinforcers (work,
friends, family) in order to be able to emit only the responses that lead to the rein-
forcing effects of the drug.
It is usually at this time the individual starts to neglect the emission of other
important response in order to use drugs that his friends, family members, and soci-
ety start to consider him as having a substance use problem. In other words, the
more a person stops to emit “appropriate and/or desirable” responses to the society
and choose to emit “undesirable and/or inappropriate” behaviors related to sub-
stance use, the more they tend to consider their consumption problematic.

Contingency Management (CM)

The name contingency management (CM) describes the intervention proposal well.
According to Skinner (1969), the term contingency can be understood as the rela-
tionship, or interrelationship, between antecedent stimuli (events that occur before
a given response), the emission of a response or behavior, and the consequences
produced by that response (consequent stimuli). These consequent stimuli can be
either reinforcing, when they increase the frequency or probability of the response
to be emitted in the future, or punitive when they reduce the frequency or probabil-
ity of this response to be emitted in the future. Thus, as the name implies, CM treat-
ment aims to manage contingencies (or even create new contingencies) in order to
modify harmful behavior patterns present in the repertoire of the individual
with SUD.
The maintenance of problematic drug use by an individual is a product of the
presence of strong (unconditioned and conditioned) reinforcers contingent on drug
use and the lack of other reinforcers contingent on alternative responses (Higgins
et al., 2004). This unequal competition between reinforcers associated with drug use
and reinforcers associated with alternative responses makes it difficult to modify the
pattern of substance use.
7 Contingency Management for the Treatment of Substance Use Disorders 81

As seen previously, experimental studies suggest that it is possible to reduce or

eliminate certain problematic behaviors that in themselves generate reinforcing
consequences (such as substance use) by reinforcing other behaviors that are incom-
patible with problem behavior (e.g., maintaining abstinence) (Higgins, 1996, 1997).
Thus, CM aims to reduce or eliminate problematic behaviors (substance use) by
reinforcing (offering prizes or tokens with a certain monetary value) behaviors that
are incompatible with those considered a problem (abstinence) (Higgins &
Petry, 1999).
The use of punishment (contingent on substance use) may be effective in some
cases, but produces undesirable consequences (counter-control) such as treatment
drop-out, aversive emotional states, and conflicts between patient and clinician(s)
(Amass & Kamien, 2004). The use of positive reinforcement, in turn, does not pro-
duce this type of negative effects. Thus, in order to extinguish undesirable responses
related to substance use, CM treatment aims to manipulate the contingencies pres-
ent in the individual’s environment by increasing the presence of positive reinforc-
ers linked to alternative responses and, when possible, incompatible with
substance use.
Creating new contingencies using natural reinforcers is always preferable as
these contingencies tend to remain after the end of treatment. However, it is very
common that the behavioral repertoire of substance users are quite impoverished
(especially the most severe cases) and that most of the reinforcers linked to this
repertoire are related to substance use. Thus, CM treatment develops new contin-
gencies with arbitrary reinforcers (not naturally produced by the natural or social
environment) that are contingent to responses alternative to substance use, and
hence, promote abstinence and other desirable responses (Higgins & Petry, 1999;
Petry, 2000).
For more than 30 years, CM has been applied in the treatment of cocaine and
other drug addictions (Prendergast et al., 2006). Studies with this technique present
high methodological rigor and systematically achieve the best results in terms of
adherence to treatment, achievement, and maintenance of abstinence (Higgins et al.,
1991, 1994; Stitzer & Bigelow, 1978).
One of the most studied methods of CM, with the greatest evidence of effective-
ness, is termed vouchers CM (Higgins et al., 1993). In this method, vouchers with a
certain monetary value (that can be exchanged for products present in the commu-
nity) are given to a patient immediately after he/she emits a desired behavior (e.g.,
abstinence, adhering to pharmacological treatment). These vouchers act to reinforce
a response that is incompatible with the emission of problematic response (e.g.
maintaining abstinence is incompatible with consuming substances). An important
point to consider regarding the use of tokens as reinforcers is that, because they
represent the possibility of obtaining products and goods, these tokens act as gener-
alized conditioned reinforcers (because they represent everything that can be
obtained with that monetary value). Since they act as generalized reinforcers, they
are not very sensitive to satiation (they do not reduce their reinforcing value) and
are, therefore, ideal for this type of procedure.
82 V. Simões et al.

In general, these reinforcers are given systematically (2–3 times a week) to

increase the reinforcing magnitude of the consequences produced. As the patient
performs these behaviors consecutively, the value received in tokens increases. This
increase in reinforcing value aims to promote longer-lasting changes and the main-
tenance of abstinence on a continuous basis, as well as to highlight that longer
periods of abstinence are more valued than shorter periods. When the patient cannot
present these behaviors (e.g., cannot become abstinent/relapse) he/she is encour-
aged to try again, but does not receive vouchers in that given day.
Using this methodology, Higgins and colleagues developed in 1991 the first
study that became a reference for all other CM studies that followed. To allow a
better understanding of how the CM is applied, a description of the whole proce-
dure, as well as the results obtained in this experiment, will be presented here. In
this study, cocaine-dependent participants were randomized into two groups (one
receiving standard treatment and the other receiving standard treatment plus CM).
In both groups, participants were encouraged to leave 3 urine toxicological samples
per week. While the control group did not receive any form of recompense for test
results, the CM group could earn vouchers for submitting negative cocaine samples.
For the CM group, the first test with a negative result (done immediately and in front
of the patient) guaranteed the patient a $2.50 voucher gain. To encourage continued
abstinence, each consecutive negative test increased in value by $1.25. However, if
the patient failed to submit a test or the sample tested positive for cocaine, the
patient did not receive a voucher that day and future voucher were reset to their
original value. This reduction in voucher value was intended to punish cocaine use
responses.
Since for individuals with a cocaine use disorder, money is directly associated
with cocaine use, vouchers were not transformed into money, but rather into prod-
ucts and goods available in existing in the community (e.g., supermarket purchases,
concert tickets). If the patient remained abstinent throughout the treatment
(12 weeks) he would receive $997.00 in products and/or services.
Results obtained in this study showed that 85% of the patients receiving CM
remained in treatment during the 12 weeks compared to only 33% of the control
group patients (p. < 0.05). In addition, 46% of patients receiving CM remained
abstinent for at least 8 weeks compared to zero in the control group (p. < 0.05).
Subsequent randomized controlled trials replicated the same results (Higgins et al.,
1993, 1994).

 ffectiveness of Contingency Management in the Treatment

E
of Substance Use Disorders

CM applied to SUD treatment is one of the most-studied psychosocial interven-

tions. Randomized clinical trials in CM have been conducted in the United States
(Higgins et al., 1991, 1993, 1994), Spain (Garcia-Fernandez et al., 2011;
7 Contingency Management for the Treatment of Substance Use Disorders 83

Secades-Villa et al., 2015), United Kingdom (Weaver et al., 2014), Switzerland

(Petitjean et al., 2014), China (Chen et al., 2013; Jiang et al., 2012), and Brazil
(Miguel et al., 2016, 2019).
Meta-analysis studies suggest that CM applied alone, or in conjunction with
other cognitive behavioral treatments, is effective in promoting continued absti-
nence and treatment adherence among individuals dependent on a wide variety of
substances (Lussier et al., 2006, Prendergast et al., 2006). More specifically, meta-­
analysis studies have found that the CM has an effect size ranging from moderate to
high (this being the largest effect size found for any psychosocial treatment for
SUD) (Lussier et al., 2006).
The results obtained in CM studies were so positive that in 1998 the National
Institute on Drug Abuse (NIDA) developed a practical manual on how to properly
implement CM in open cocaine treatment programs (Budney, 1998). In 2007, the
National Institute for Health and Clinical Excellence (NICE) recommended CM to
the UK’s National Substance Abuse Treatment Agency (Pilling et al., 2007).

Contingency Management for Crack Use Disorder in Brazil

Recently, the first study of CM in Brazil was performed (Miguel et al., 2016, 2019).
In this study, which used the CM voucher’s model, 65 crack-dependent individuals
who sought treatment at the Vila Maria Medical Specialty Outpatient Clinic (AME-­
Vila Maria), in the North Zone of São Paulo, were randomized into two groups. In
total, 32 subjects were allocated to the control group, and 33 were allocated to the
experimental group. In this 12-week study, the control group received the standard
intervention offered by AME-Vila Maria, while the experimental group received the
same standard treatment offered by AME-Vila Maria in association with CM. The
CM procedure consisted of reinforcing the abstinence from crack-cocaine. In this
study, after the first crack-cocaine negative urine sample was submitted, the partici-
pant immediately received a voucher with a monetary value of R$ 5. This value
increased by R$ 2 for each consecutive crack-cocaine negative sample, to a maxi-
mum value of R$ 15, thus increasing from R$ 5 to R$ 7, 9, 11, 13, and 15, respec-
tively. If the participant left the three negative weekly samples for crack-cocaine, he
also received a bonus of R$ 20.
The results of this study demonstrate that CM was more effective in reducing
crack-cocaine use and promoting longer periods of crack-cocaine abstinence
when compared to standard treatment. In CM treatment, 21.2% of subjects
remained abstinent from crack-cocaine during all 12 weeks of the study, com-
pared to none in the control group. CM was also more effective in promoting
treatment retention. In total, 51.5% of subjects adhered to all 12 weeks of treat-
ment compared to none of the control group (Miguel et al., 2016). Significant
differences in favor of CM were also observed with respect to participation in
treatment and in reducing marijuana, and alcohol use (Miguel et al., 2016).
Furthermore, a greater reduction in depressive and anxious symptoms was
84 V. Simões et al.

observed among participants exposed to CM (Miguel et al., 2017). Finally, when

asked about their experiences with CM treatment, the vast majority of participants
highlighted that CM is easy to understand, that they liked to receive this type of
treatment, that they thought CM was fundamental in their treatment response, and
that they believed other crack- cocaine users would benefit from this intervention
(Miguel et al., 2018).

Clinical Case

This will be a brief account of a family therapy where CM was effective in treating
the cocaine use of one of the relatives.
In 2015, Marcos’ parents sought psychological care as they had recently dis-
covered that Marcos was using cocaine with a certain regularity. Marcos is
24 years old, single, and works promoting night-time events and parties in São
Paulo, Brazil. As a child and adolescent he was always very sociable and cheerful,
but had a lot of academic difficulties, which led him to repeat a school year twice
and to change schools on three occasions. At the age of 17 he was diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD) and started to be medicated
with Ritalin, using this medication until his college years. After graduating from
high school, Marcos went to live in São Paulo city (his family lives in the coun-
tryside of the state of São Paulo) to go to business school. In a period of 2 years,
Marcos studied and abandoned three different colleges, having always had a very
weak academic performance.
During this period Marcos also began to work and stand out in the promotion of
night-time events and parties (field where he works until today). Two years ago
Marcos tried cocaine for the first time and started using it sporadically in the follow-
ing months. In the last year, this use became more frequent (2–4 days per week) and
Marcos began to have professional, financial, and family problems. In a few months,
Marcos began to show a pattern of excessive spending (much higher than he earned),
which culminated in a debt of R$ 100,000. It is worth mentioning that Marcos’ fam-
ily has a good economic condition and has always paid all of Marcos’ living costs
(house, car, house and car bills, cell phone, insurance, income tax, etc.), making this
spending pattern even more problematic. During this period, his family found
cocaine in his car and, while talking to one of his friends, discovered that Marcos
was using cocaine regularly. After making this discovery they decided to seek treat-
ment. Initially they encouraged Marcos to do individual therapy, but Marcos did not
adhere and continued to use cocaine. Therefore, in order to ensure Marcos’ partici-
pation, they sought family therapy.
In the first consultation with the family, Marcos denied that his use was fre-
quent and reduced the negative impact that cocaine had in his life (quite com-
mon among substance users). At the same time he wanted his parents to pay his
debts (a recurring pattern of response historically reinforced by his father).
Understanding that Marcos’ main complaint was the financial issue while his
7 Contingency Management for the Treatment of Substance Use Disorders 85

parents’ complaint was cocaine use, the therapist proposed CM treatment using
Marcos’ need for financial help to reinforce his abstinence from cocaine. After
a negotiation listening to all the points and considerations of the family mem-
bers, a personalized CM strategy was developed based on a compromise after
considering both Marcos and his family’s needs/desire (it is very important that
all those present in the therapy process participate and agree on the CM strategy
to be employed).
The CM strategy developed consisted of the following actions: First, the debt
was financed in 3 years with instalments of 4000 reais per month. From the rene-
gotiation of the debt it was agreed that Marcos would do two urine tests per week
until his debt was paid in full (a nurse was hired to do the urine tests since his
family lives 3 h away from São Paulo). For each negative cocaine test Marcos
would earn 150 reais. If the two tests of the same week were negative he would
receive an additional 200 reais. Finally, if all the tests were negative during the
month, Marcos would receive an additional 2000 reais. Thus, if all the tests of an
entire month were negative for cocaine (total abstinence in this period), Marcos
would earn exactly 4000 reais (value of the debt installment). On the other hand,
a positive exam or not being submitted to an exam would result in a loss of 2350
reais in that month.
This reinforcement scheme was chosen to motivate total abstinence and not only
the reduction of cocaine consumption. In addition, all of the amount earned by
Marcos (paid by the parents in practice) would be destined directly to the payment
of the debt. If Marcos could not remain 100% abstinent, it would be his responsibil-
ity to add the amount necessary for the payment of that month’s installment. If this
did not happen, Marcos’ car would be taken by his parents and Marcos would only
get it back after reaching one month of complete abstinence from cocaine. Finally,
if he could not pay his debt (which in this case would also mean continuing to use
cocaine), his car would be sold to pay his debt.
It is important to emphasize that Marcos, being of age, has the right to choose
whether or not to use cocaine or to participate in the treatment. The main contin-
gency that the treatment is proposing here is that Marcos’ parents do not continue
paying his expenses and debts if he continues using cocaine. In doing so, this con-
tingency scheme uses positive (debt payment) and negative (withdrawal from the
car) reinforcers to increase Marcos’s abstinence response.
This treatment has been applied for exactly 15 months. In the first 3 months,
Marcos showed an intermittent pattern and had 60% of his tests negative. During
this period, he was able to use his own money to pay his total monthly debt in the
first two months, but not in the third month (which led to losing his car in the fourth
month). Since then, his performance has been excellent. In the 12 months that fol-
lowed, Marcos was completely abstinent in 10 months, reached a 6-month sequence
of continuous abstinence and at no time had more than two consecutive positive
tests. Along with this, Marcos learned to control his spending and is paying his debt
on time (either by demonstrating his abstinence or paying out of his own pocket).
Finally, his professional career has improved, as has his relationship with his family
members.
86 V. Simões et al.

Final Considerations

CM is among the most effective treatments for SUD. CM is effective in promoting

continued abstinence, decreasing substance use and increasing treatment adherence
and participation.
Several studies in CM show that CM can be generalized to the treatment of sev-
eral substances use disorders (e.g., cocaine, alcohol, heroin, tobacco) and different
subpopulations (adolescents, pregnant women, individuals with severe mental
health, homeless individuals). Efforts from the academic community, mental health
providers, and society in general are needed to disseminate this form of treatment
and encourage the implementation of CM as an integral part of the treatment offered
in outpatient services for SUD in Brazil and abroad.

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Chapter 8
Cue Exposure Therapy for Substance Use:
A Complement to Functional Analysis

Rodrigo Noia Mattos Montan and Roberto Alves Banaco

Introduction

Substance use disorder (SUD) manifests itself as a harmful condition in the lives of
millions of Brazilians, and it has become an area of study of different approaches
that investigate the acquisition and maintenance of drug use and drug dependence.
In 2015, the Brazilian population showed a significant number of people who
needed treatment: around 2.3 million people between the age of 12 and 65 showed
dependence to alcohol and 1.2 million to other substances (marijuana, solvents,
benzodiazepine tranquilizers, amphetamine-type stimulants, cocaine, crack, opi-
ates, and ketamine—except alcohol and tobacco). These numbers represent a preva-
lence of 1.5% of the population for alcohol dependence and 0.8% for other
substances dependence (Bastos et al., 2017). An estimate of 1.6 million individuals
received treatment in their lifetime for substance use, which accounts for 1.1% of
the Brazilian population (Bastos et al., 2017, p. 141).
Among the different approaches and theoretical models that study SUD, we can
find cognitive behavioral therapy (CBT) (Zanelatto & Laranjeira, 2018), motiva-
tional interviewing (Miller & Rollnick, 2012), psychopharmacological intervention
(McKim & Hancock, 2012), contingency management (Higgins et al., 2007), and
behavior-analytic approach (Banaco & Montan, 2018). The last one focuses on the
topic incorporating practices from different clinical models, namely functional ana-
lytical psychotherapy (FAP) (Souza & Oshiro, 2019), acceptance and commitment
therapy (ACT) (DuFrene & Wilson, 2012), contingency management (Miguel et al.,
2016), dialectical behavior therapy (DBT) (Melo et al., 2018), and cue exposure
therapy (CET) (Conklin & Tiffany, 2002). CET is an intervention proposal that is

R. N. M. Montan () · R. A. Banaco

Associação Paradigma – Centro de Ciências e Tecnologia do Comportamento (Paradigma
Association – Center for Sciences and Technology of Behavior), São Paulo, Brazil
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 89

S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_8
90 R. N. M. Montan and R. A. Banaco

still scarcely used in the clinic for substance abuse, and its effectiveness remains
under investigation (Conklin & Tiffany, 2002; Martin et al., 2010).
Despite being a topic of debate, CET studies with SUD have contrasting results
from those obtained by exposure and response prevention (ERP)1 in psychological
treatments applied to other psychiatric disorders. ERP has proven effective in the
treatment of phobias, posttraumatic stress disorders, and obsessive-compulsive dis-
order (Botella et al., 2017; Maples-Keller et al., 2017; Opriş et al., 2012). Given this
scenario, we must investigate the gaps present in studies on the topic and develop
methodological designs to fill such gaps. This chapter aims to shed light on the theo-
retical model on which CET is based, its clinical implications in substance use, and
methodological issues present in CET studies.

Theoretical Model of Cue Exposure Therapy

Classical Conditioning on the Substance Effect

In literature, CET is referred to as different terms, the most common being: cue
exposure and cue exposure therapy. The term cue exposure refers to a method that
assesses the degree of dependence (referred to as cue reactivity) and assists the
patient to identify high-risk stimuli to relapse. In experimental models, the same
terms are used to study responses of the organism in the presence of conditioned
stimuli (Childress et al., 1988; Saladin et al., 2006). The term cue exposure therapy
is commonly used in studies that aim to habituate or extinguish conditioned
responses, both at operant and respondent levels (Mellentin et al., 2017).
The term cue exposure (CE) refers to a basic process contemplated by the classi-
cal conditioning theory (or Pavlovian conditioning). To elucidate this process, let us
take cocaine –an unconditioned stimulus (US)— as an example. When administered
by any access route (intranasal, intravenous, or pulmonary/smoked), it elicits uncon-
ditioned responses (UR) that require no previous learning history. Any organism
that ingests cocaine will show URs such as altered heart rate and body temperature,
and feelings of euphoria. A neutral stimulus that has been previously paired with
cocaine use acquires properties of a conditioned stimulus (CS). For instance, if
cocaine is always administered where there is a “bag of cocaine” –inside a restroom,

1
Here, the results from the studies of both treatments are compared because in Brazil, ERP and
CET are treated as the same therapy, being different from the international literature that under-
stand them as different treatments. The international literature specifies ERP as a therapy offered
for treating posttraumatic stress and anxiety disorders, such as phobias and obsessive-compulsive
disorder, while CET is referred to as a treatment offered only for SUD. Despite having different
names, ERP and CET base their practice on a process, contemplated by the classical conditioning
theory, that includes extinction training through stimulus exposure and response prevention.
Therefore, in Brazil, for having the same theoretical basis and methods, ERP and CET are seen as
the same and both are referred to under the same term “exposure and response prevention therapy.”
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 91

in the presence of a user friend etc.—it will cause these environmental cues –if
repeatedly associated to drug use—to acquire a CS function. When the organism is
reexposed to these stimuli –even in the absence of the US (cocaine)—a conditioned
response (CR) is elicited, which may consist of a change in heart rate and body
temperature, and a feeling of euphoria. The more often the stimulus is paired with
cocaine, the more likely the CR is to occur and greater is its intensity when the
organism is reexposed to it. According to Drummond et al. (1995), when a CS is
presented, its related CR depends on the organism’s history with it. As they have
eliciting and evoking properties, drug-related CSs increase the probability of active
drug-seeking and self-administration. (Drummond et al., 1995). This happens
because stimuli paired with substance use are followed by aversive bodily changes,
which only cease after its ingestion. Thus, a history of operant conditioning begins,
involving seeking and finding the substance, followed by its use, which removes
aversive body states. For this reason, they acquire the function of motivating opera-
tions (MOs), given that, in the presence of CSs, substance-seeking and self-­
administration are more strongly evoked –that is, their occurrence becomes more
likely when CSs are present rather than absent. To assess the strength of a response,
elements such as latency, rate, and (when subjected to extinction) resistance can be
measured (Michael, 1980). MOs acquire control over responses because the operant
conditioning history of ingesting the drug produced both negative and sometimes
positive reinforcing consequences. A probable positive reinforcing consequence –
which further strengthens substance-seeking and self-administration—is the effect
the substance has on the organism, producing states of pleasure. A probable nega-
tive reinforcing consequence, on the other hand, is the removal of CRs due to their
aversive properties – and this is proof that they are aversive: they become the MO
for their own removal, through the operant response of substance-seeking and use.
Pavlov (1927) was the first to demonstrate and suggest studies on classical con-
ditioning and drug use in an experiment that administered morphine into dogs.
Other researchers –contrary to mentalist approaches of the time—demonstrated that
stimuli that signal the opportunity for substance use elicit CRs at a respondent level,
as well as evoke operant drug-seeking responses (e.g., Siegel, 1979; Stewart et al.,
1984; Wikler, 1948). Theorists present three basic ways in which CSs can control
substance use by eliciting: (1) CRs similar to withdrawal symptoms (e.g., Wikler,
1948); (2) CRs that occur in the opposite direction of the effect caused by the sub-
stance (Siegel, 1975); and (3) CRs that occur in the same direction as the effect
caused by the substance (Stewart et al., 1984).
The effect of substances on the responses of organisms help us to understand
some aspects of SUD such as substance-seeking, withdrawal symptoms, substance
craving,2 and relapses. As shown previously, whereas one theoretical model infers
that CRs are opposite to the effects caused by the drug, the other shows CRs to be
drug-like and similar to those effects. Wikler (1948) described in his studies that

2
According to Banaco and Montan (2017) drug-seeking itself (operant behavior) to eliminate with-
drawal symptoms is referred to as craving.
92 R. N. M. Montan and R. A. Banaco

stimuli preceding drug use can elicit reflex responses and evoke operant responses
similar to the effects of the drug itself and noted that antecedent stimuli can cause
opposite effects to those of the drug. When studying dogs self-administering mor-
phine, he observed that substance use was maintained due to its pleasurable effects,
thus having a positive reinforcing function on the response. He also noted that the
use of morphine was maintained due to its ability to attenuate and remove aversive
symptoms from the withdrawal effects, negatively reinforcing the response. In an
attempt to explain relapse, the author proposed the conditioned withdrawal model
contributing to the understanding of the role of respondent conditioning on sub-
stance use –a view that influences behavioral approaches until today. Wikler (1948)
demonstrated that several morphine CSs elicited CRs that resemble morphine with-
drawal symptoms, and relapse was interpreted as a response that produces relief
from aversive withdrawal symptoms.
When proposing a similar model, Siegel (1975) stated that drug-related CRs
occur in the opposite direction to their unconditional effects –model commonly
known as the conditioned preparatory or compensatory response. Although Siegel
(1975) conceptualizes and observes drug CRs in an alternative way, his view seems
to have been influenced mainly by Winkler’s model. On the other hand, Glautier and
Remington (1995), when analyzing the two models, explain that Wikler’s condi-
tioned withdrawal model and Siegel’s conditioned compensatory response model
are similar. Firstly, both recognize that the substance has a biphasic action –that is,
the initial effects of the substance on the organism are identical to the effect of the
substance itself. Secondly, in both models, negative reinforcement is the primary
mechanism by which CRs contribute to substance use. That is, compensatory
response processes are given as aversive –just as the symptoms of conditioned with-
drawal—in a way that the aversive state is reduced by ingesting the substance,
thereby negatively reinforcing its use. However, Siegel (1989, p. 158) argues that
the term conditioned compensatory response can in fact be called withdrawal symp-
tom. Nevertheless, Cunningham (1998, p. 250) classifies both models as parts of the
same whole. Although similar, Siegel’s model presents an essential characteristic
regarding the interaction of tolerance upon the effect of the substance and how it is
modulated by the presence of CSs during substance use. It is argued that drug-­
opposite CRs added to the drug URs result in the conditioned tolerance effect.
(Glautier & Remington, 1995).
Conversely, a second alternative model exposed by Cunningham (1998) regard
CRs as similar to the effects of the substance. The model suggests that USs, when
paired to substance use such as alcohol and morphine, elicit physiological responses
equal or similar to the effects of the substance itself (Lynch et al., 1973). This was
observed by Pavlov (1927) when studying the effect of respondent conditioning on
substance use. He observed in his experiment that a hypodermic morphine injection
resulted in nausea, salivary secretion, followed by vomiting and sleepiness. After
5–6 days of morphine administration, stimuli prior to morphine injections –such as
the presence of the experimenter, the opening of the syringe box, fur-trimming over
a small skin area, alcohol sterilization, and even the injection of other fluids—suf-
ficed to produce CRs similar to URs.
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 93

Although Pavlov registered supposedly aversive symptoms, the second model

also shows that exposure to drug CSs elicit drug-like CRs that increase the reinforc-
ing value of the stimulus associated to it. Thus, CSs promote the evocation of drug-­
seeking or self-administration responses just as priming doses of the substance do,
along with reinstating responses of self-administration after extinction (Cunningham,
1998; de Wit & Stewart, 1981). In a study by De Wit and Stewart (1981), mice were
trained to self-administer cocaine (1 mg/kg/injection), and trained in daily test ses-
sions of self-administration and extinction. This stage was followed by either the
administration of priming doses of cocaine or exposure to drug CSs during extinc-
tion, and measurement of the first self-administration response latency. They
observed that drug CSs restore self-administration responses just as priming doses
of cocaine reinstate self-administration after extinction.
Stewart et al. (1984) argued that “compulsive drug use, even of opiates, is main-
tained by appetitive motivational processes, that is, by the generating of positively
affective motivational states” (p. 252). This model assumes that appetitive and plea-
surable effects of drug CRs establish the use of the substance as reinforcing, thus
referring less to the effects of negative reinforcers produced from the relief of aver-
sive withdrawal symptoms. However, despite being different models, one assuming
CRs as drug-opposite and the other drug-like, both emphasize that reexposure to
CSs associated to the context of drug use produces relapses during prolonged peri-
ods of abstinence. In other words, both models explain relapse (Cunningham, 1998).
On the other hand, only the compensatory response model explains the tolerance
process, which is described as the need for a gradually greater intake of substance,
during the opportunities for its use, in order to obtain its same effects (see a more
detailed description below).
Besides constituting theoretical models that entail behavioral processes involved
in substance use, the literature still has been studying the direction of CRs starting
from psychological or physiological states in the organism (e.g., Niaura et al., 1988;
Schwarz & Cunningham, 1990; Siegel, 1979).
Glautier and Remington (1995) suggest that the variable of interest in CE studies
should be the substance use itself, since it is in the interaction between respondent and
operant behavior that the behavior of drug-seeking and self-administration of sub-
stance occurs. Therefore, when we consider the variables that influence not only sub-
stance use and the role of tolerance upon the increase of drug intake but also the
patient’s relapse during abstinence, it is known that respondent and operant condition-
ing play an important role in the acquisition and maintenance of abusive substance use.

 onditioned Compensatory Response and Its Role

C
in Tolerance, Relapse, and Overdose

The same mechanisms that explain conditioned compensatory responses also

explain tolerance. When performing manipulations to assess the effect of drugs,
Siegel (1975, 1979, 1989) observed that drug CSs increase motivation for their use
94 R. N. M. Montan and R. A. Banaco

as they elicit CRs in the opposite direction of URs, and that the presence of CSs
interferes in the effect of the drug –which helps to understand the development of
drug tolerance by the organism. When a subject is said to have acquired tolerance to
a substance, it means that he or she must use progressively larger doses to achieve
the desired effects. The use of larger doses has an effect in determining abusive
substance use (Glautier & Remington, 1995). We can assume that if substance use
happens in the presence of CSs, its effect would be attenuated by compensatory CRs
that precedes the systemic stimulation of the substance in the organism. When the
pairing between the stimuli present in the context of substance use during its admin-
istration and the systemic stimulation of the drug in the organism is strengthened by
frequent use, the substance is expected to have its effects increasingly cancelled,
given the increased magnitude of compensatory CRs (Siegel, 1979). In this theo-
retic model, tolerance to drug effects is determined by situational factors (Glautier
& Remington, 1995). This effect was demonstrated in a study by Siegel et al. (1978)
in which mice showed larger tolerance to morphine’s analgesic effects when the
administration occurred in situations in which the administration had been paired
with the contexts of use. They also found that tolerance to morphine effects was
cancelled when the drug administration setting suffered changes.
To illustrate an interaction between the effects of the substance and compensa-
tory CRs, Banaco and Montan (2018) adapted and transformed a figure from Siegel
(1979) (see Fig. 8.1). Figure 8.1 shows the effects of substances (panel A); the CSs

Fig. 8.1 Curves of the effects of drug administration (A, B, and C) and the effect of stimuli that
consistently precede drug intake (graph D). (Source: Adapted and transformed by Banaco and
Montan (2018) from Siegel (1979))
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 95

that precede drug intake and their effects on tolerance (panel B); and withdrawal
symptoms, relapse, and overdose (panels C and D). In the figure, the effect of the
substance (DRUG UCR – drug unconditional response) is represented by an
increased response level (+) from baseline and the drug-compensatory CR (DRUG
CR – drug conditional response) is represented by a decreased response level (−) in
the opposite direction of the DRUG UCR. Figure 8.1 aims to illustrate that the effect
of the substance depends on the interaction of the two types of responses that occur,
the effects of one being opposite to the effects of the other.
Panel A shows the effect of the substance in the occasion of its first administra-
tion. In this case, the substance is not conditioned or associated with stimuli or
environmental cues that precede its intake –the substance then has a full effect. The
positive curve (+) represents the effect of the substance that increases until its peak
and decreases according to the substance’s pharmacokinetics due to the time elapsed
since its ingestion. Panel B shows that, when there is an increase in the frequency of
administration of the substance, and the ingestion response becomes conditioned by
environmental stimuli, such ingestion of the substance is no longer accompanied
just by pharmacological URs itself, it is then followed by drug-compensatory CRs,
represented by the negative curve (−) in the graph. Panel B also shows that the
effect resulting from substance use (UR – represented in hatch) is smaller than the
one observed in its first administration because it becomes attenuated by compensa-
tory CR, resulting in the tolerance effect. Panel C demonstrates the interaction
between drug UR and compensatory/preparatory CR when there is a history of sev-
eral substance administration events in a context with the same environmental cues.
Drug UR now becomes minimal in the presence of drug CR, demonstrating a high
tolerance to the drug. Panel C also illustrates a biphasic effect: a small effect of the
substance intake is followed by another effect in the opposite direction of drug
UR. As an example, when mice continued to receive morphine doses, they became
tolerant to its analgesic effects and started to experience hyperalgesia (Siegel, 1975).
This mechanism also explains withdrawal symptoms and active substance-seeking,
because a dose that produces minimal effects also produces subsequently compen-
satory responses, which are themselves aversive to the body. When this happens,
substance-seeking would have the function of eliminating withdrawal symptoms
caused by the minimum dose. Panel D shows that when the organism is exposed to
CSs before ingestion, they produce uncomfortable conditioned preparatory
responses through reflex mechanisms, and that, depending on the substance, it elic-
its tachycardia, sweating, hypoglycemia, changes in breathing and decreased oxy-
gen, among others. This mechanism explains withdrawal, which are symptoms that
appear when the body is exposed to stimuli that precede the ingestion of the drug,
but without taking it. Let us take as an example a person with heroin use disorder
who had its material (spoons, syringes, and lighters) paired with the ingestion of the
drug. When coming into contact with these stimuli, compensatory responses –which
have the function of homeostasis and serve to protect the organism from the harmful
effects of heroin action—end up eliciting aversive symptoms in the absence of the
drug, such as hyperthermia, chills, diarrhea, and hyperalgesia. For aversive CRs to
96 R. N. M. Montan and R. A. Banaco

be eliminated, the person resorts to substance use, thereby negatively reinforcing

drug-seeking (Banaco & Montan, 2018).
Panel D also illustrates that the amount that previously produced positive or neg-
ative reinforcing effects now has a minimal effect, which explains why the individ-
ual needs to use increasing amounts to experience the reinforcing effects of the
substance. This results in a further drug-seeking and an increased dosing, thus
establishing a state of dependence (Banaco & Montan, 2018).
According to Banaco and Montan (2018), the action of compensatory CRs may
also account for an overdose. In their article, they present a hypothetical case in
which an individual always ingests the same dose in the same situations –thus in the
presence of the same CSs— and, on the account of that, has already developed toler-
ance, along with being used to ingesting a known quantity that is sufficient to
achieve the intended effect under these conditions. Following the authors’ example:
(…) a cocaine dependent person knows how many “bags” they can sniff to achieve behav-
ioral arousal. As he or she goes to the usual place of consumption (bar, club etc.), their body
gradually prepares itself, through anticipatory responses, for the drug to enter the organism,
and "craving" increases. However, if cocaine is presented outside their usual consumption
environment (for example, in the workplace) which had not been associated with use, the
commonly consumed amount will have a much greater effect than the intended familiar
one, thus causing overdose with serious risks. This is because the stimuli that compose the
work environment do not have the power to elicit the compensatory effects of the drug in
anticipation (p. 125).

By understanding the role of compensatory CRs in SUD, we could see that the
Pavlovian conditioning theory explains tolerance, withdrawal symptoms, and over-
dose. We shall now address the role of respondent processes in relapse. Respondent
processes in substance use states that compensatory CRs tend not to dissipate over
time without extinction. CSs can lose the control over CRs if presented many times
without being followed by USs –in this case, the drug. For CSs to lose their ability
to elicit CRs, several CS presentations without pairing it with the US (drug) are
necessary. This implies that treatments with long abstinence periods in places that
have no occurrence of drug CSs fail to extinguish CRs. In other words, if an indi-
vidual presents compensatory CRs in an environment that has drug cues, removing
the individual from this eliciting environment for long “detoxification” periods does
not affect the ability of drug CSs to elicit CRs, as the extinction of the CS–US pair-
ing does not occur. If individuals spend long hospitalization periods in rehabilitation
clinics, upon returning to their natural environment –previously associated with
substance use—they are likely to present compensatory CRs, which can be elimi-
nated through using the substance, thus configuring a relapse (Siegel, 1979).
Even if an individual has been admitted to rehabilitation clinics, several drug CSs
may be present in the seclusion environment. For instance, heroin users may require
spoons and lighters to administer the substance, which can be found in the hospital-
ization environment. Even if they elicit withdrawal and craving CRs, they will not
be followed by heroin in this setting. Presenting these anticipatory stimuli (spoons
and lighters) without pairing them to drug use over time causes them to lose their
control over the body that becomes habituated to them (by extinguishing the CS–US
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 97

pairing), thus ceasing to present withdrawal and craving responses when such stim-
uli are present. When these individuals return to their natural drug use environment,
they are reexposed to another group of stimuli that had not been present in the treat-
ment environment, thus keeping intact those stimuli pairing relations established
until the moment before admittance. These can be former user partners or even the
room where they used to do drugs at home. All those stimuli would be sufficient to
elicit withdrawal or craving CRs, and now these stimuli that were not submitted to
the extinction process would cause unpleasant states and drug-seeking responses,
and by doing so, drug use (relapse) can help eliminate these aversive states (Banaco
& Montan, 2018).

Clinical Implications of Cue Exposure

Findings and theories derived from the literature that investigate the role of respon-
dent conditioning on substance use have influenced clinical practice and research
within the field of behavior analysis. In the treatment context, CE is studied and
applied within CET. It systematically exposes substance abusers to drug CSs, usu-
ally within a clinical setting that prevents its ingestion, thus contributing to the
extinction of responses elicited by drug related environmental stimuli. The rationale
behind this approach is based on the principles of respondent extinction processes.
The classic conditioning literature presents great evidence that repeated exposures
to a CS in the absence of the US decreases the strength of CRs and extinguishes its
conditioned function, thus returning the CS to a state of neutral stimulus for the
target response. The objective is to reduce physiological reactions (compensatory
CRs) caused by CSs that are present in real life environments, with the benefit of
lowering the discomfort caused by the eliciting stimulus, which, in general, pro-
duces craving. It also tends to reduce the subsequent seeking for abusive drug use
(now operant), which is ultimately reinforced by the removal or reduction of aver-
sive symptoms present when individuals experience craving (Drummond
et al., 1995).
To assess the conditioning properties of stimuli associated with the drug, URs
and CRs are deliberately elicited in a controlled environment with the presentation
of CSs historically paired with the natural substance use environment. The most
commonly collected UR and CR measures are physiological responses –such as
heart rate, skin conductance, and temperature—and self-report measures –via ques-
tionnaires and analog scales that assess urge ratings for a particular substance
(Carter & Tiffany, 1999). CET consists of presenting CSs represented in the form of
photos and videos, as well as auditory, in vivo, imaginal, and virtual stimuli (Carter
& Tiffany, 1999; Saladin et al., 2006).
98 R. N. M. Montan and R. A. Banaco

Kinds of Cue Exposure

As explained earlier, CE is commonly used as an initial assessment method that

investigates the level of dependence by observing cue reactivity and helps the
patient to identify high-risk stimuli for relapse. CET, on the other hand, is an inter-
vention method whose goal is to habituate or extinguish CRs. Both consist of pre-
senting CSs with the use of appropriate stimuli that, human subjects, were regularly
present either during drug use, preparation, or anticipation of drug intake (Carter &
Tiffany, 1999; Saladin et al., 2006).
In the field of substance use, the variety of stimuli conditioned to substance
intake and its effect is broad, which makes identifying all CSs an unattainable task.
According to Drummond et al. (1995), stimuli that can be paired with the use of
substances can be both exteroceptive and interoceptive. Exteroceptive stimuli can
include those that are present before ingesting the substance, such as sight, smell, or
taste of the alcoholic beverage or cigarette, sight of crack pipe, or crack rock itself.
Exteroceptive stimuli may also include drug-taking rituals, which involve the prepa-
ration or administration of the substance before ingestion; advertisements of legal
substances; seeing a place of consumption; listening to a musical stimulus associ-
ated with drug use; and temporal stimuli –such as the time of day or day of the week
when the episode of drug use usually occurs. Interoceptive stimuli range from sen-
sations of the substance entering the body – e.g., passing through the stomach or
nasal airways—to the effects of the substance on neuroreceptors. A dose of the
substance can also function as an MO and evoke successive self-administration
responses. This effect is known as the priming dose effect, which can be observed in
alcohol users who, after a long period of abstinence, avoid the first sip in order not
to evoke further self-administration responses. Interoceptive stimuli can also include
moods or emotions –such as anger, sadness, or euphoria—and thoughts—such as
self-constructed rules about the effects of the substance. Other stimuli that can be
considered as interoceptive are withdrawal symptoms that occur a few hours after
the effect of the substance in the body ceases and, according to the literature already
presented here, leads the individual back into contact with CSs that produce com-
pensatory CRs. Regardless of which of these orders the stimulus belongs –public or
private—both exteroceptive and interoceptive stimuli can acquire a function of
motivating operation and/or eliciting stimulus, producing effect upon responses at
the operant and respondent level.
Given the wide variety and properties of stimuli that are conditioned to substance
use, researchers and clinical psychologists use different forms of stimulus exposure
in an attempt to access and present them in experimental and clinical settings
(Araújo & Lopes, 2013; Monti et al., 2002; Saladin et al., 2006). To assess the level
of dependence through cue reactivity and/or the need and choice of therapeutic
intervention, stimuli are most commonly presented in the form of photos, videos,
audios, in vivo, imaginal, and virtual stimulation (Bordnick et al., 2009; Carter &
Tiffany, 1999). Photographic stimuli show two-dimensional images of people using
the substance or the image of the substance itself, for example. Video stimuli
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 99

present images of people performing drug rituals of preparing and administering the
substance either in places of use or others that have been related to the effect of the
substance. Auditory stimuli present the sound of people talking about the substance,
the sound of it being served, prepared, and ingested, or sounds that surround drug
use environments (sexual intercourse, for example). In vivo stimulation presents the
substance itself or a simulated substance with the same appearance, as well as the
material used to administer the drug –which may be glasses or cups with alcohol,
paraphernalia kit for smoked drugs containing pipe, lighter, or rolling paper. In
in vivo presentations, the individual is asked to handle the material and perform the
preparation ritual without using the substance. They are also instructed to smell it
and describe its properties that trigger the desire to use it.
Due to the difficulty in accessing and bringing certain stimuli to a clinical setting –
such as places or people who are linked to substance use—imaginal stimulation has
been used as an alternative to circumvent this obstacle. Patients are asked to close
their eyes and imagine situations associated with drug use, such as family conflicts,
induction of emotional states, imagine themselves buying the substance from the
dealer, or inside a bar or market.
Finally, CE and CET also use virtual stimuli. In this case, the patient is immersed
in a three-dimensional virtual environment specially created for this application.
The stimulation occurs through the presentation of places where people use sub-
stances, virtual manipulation of the substance, and access to situations that present
social pressure –such as offers and invitations to use the substance.

Topographies

In the study with psychoactive substances, cue exposure results in reactions that
occur at both respondent and operant levels and, among the operant, also at verbal
levels. Each of them can be measured by certain instruments that, taken together,
form a more comprehensive assessment of the target problem.
As means to assess respondent responses, the effects of CE have been observed
through: heart rate, respiration, body temperature (Childress et al., 1988); sweat
gland activity (galvanic skin resistance, skin conductance, etc.) (Carter & Tiffany,
1999); salivation (MacKillop & Lisman, 2008); and limbic activation (amygdala,
anterior cingulate, temporal pole, hippocampus, and orbitofrontal cortex) (Childress
et al., 1999).
We can also find measures of responses at a verbal operant level. Martin et al.
(2010) gathered studies that used craving analog scales to obtain verbal reports on
private events associated with the predisposition to emit drug-seeking or drug
administration. On analog scales, craving levels are scored from 0 to 10, where 0
means “feeling no urge to use substances” and 10 means “extreme urge to use
substances.” Analog scales are also used to measure self-confidence reports –a
term that refers to how much the client estimates the probability of exercising self-
control by not using the substance if available. It is assessed on a scale from 0 to 10,
100 R. N. M. Montan and R. A. Banaco

where 0 means “feeling not at all confident in remaining abstinent if the drug were
available,” and 10 means “feeling extremely confident in remaining abstinent if the
drug were available.”
The authors also present studies that evaluate operant and verbal responses
through follow-ups obtained 6–12 months after participants were submitted to
CET. They assessed use reduction, abstinence maintenance, and self-confidence
through questionnaires that investigate craving and other response rates during fol-
low-­up. They found no evidence to support that the efficacy of CET is superior to
other forms of substance use treatment, but it has also not been shown to be ineffec-
tive. In fact, subjects who underwent CET showed significant improvement in rela-
tion to baseline, although these improvements do not differ from other treatment
conditions.
Since some studies showed a craving reduction through extinction techniques in
smoking treatments (Park et al., 2014), and few long-term effects in alcohol users
(Mellentin et al., 2017), we can conclude that more attention should be given to
methodological issues of the interventions and more studies should be designed to
address the effects of renewal, spontaneous recovery, and reinstatement of extinct
responses, as well as the failure to extinguish the most salient conditioned cues. All
these processes would show the limitations of the technique upon the results.

Methodological Issues of CET and Effectiveness Data

Conklin and Tiffany (2002) examined 18 studies on the effectiveness of CET on

SUD conducted between 1980 and 2002 and concluded that there was little evi-
dence to support its effectiveness. Other authors identified methodological issues in
its application and suggested innovations for the technique through virtual reality,
as well as research that considers differences between subjects, and/or the use of
pharmacological approaches to increase the impact of CET (Martin et al., 2010).
Many researchers, however, argue that CET has the potential to be further studied if
new parameters are discovered, for example, number of exposure sessions, use of
multiple contexts, if appropriate stimuli are used, or if combined with other types of
therapy (Bouton & Ricker, 1994; Cunningham, 1998; Gunther et al., 1998;
Havermans & Jansen, 2003; Kim et al., 2015; Monti & Rohsenow, 1999; Rohsenow
et al., 2001; Xue et al., 2012).
Conklin and Tiffany (2002) also studied processes that threaten learned extinc-
tion and emphasize that, with the study of these phenomena, relapse can be better
understood and addressed.
Pavlov (1927), had already described that repeated non-reinforced reexposures
to CSs do not break the learned CS–US relation. The initial idea that extinction is
“unlearning” a CS–US relationship was then replaced by the notion that extinction
never occurs entirely. It replaces a learning experience with a new one, but once a
CS–US relationship has been learned, it remains intact. What is observed is that new
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 101

associations with the original CS can be developed (Conklin & Tiffany, 2002) and
can become more prominent than the old ones if more strongly reinforced.
We can also find the description of several factors or processes that threaten the
development and maintenance of extinction training acquired during CET. The
most important being: the renewal effect, spontaneous recovery, reinstatement, and
failing to extinguish the most salient stimuli.
The renewal effect refers to the reappearance of an extinct response in a context
different from the one in which the CET occurred. If a CS is paired with a US in
context 1 and the same CS is presented and extinguished in context 2, after return-
ing to the original context 1, the extinct response can be renewed (Bouton & Ricker,
1994). Consider a cocaine user who uses drug at home (context A) and receives
CET sessions with in vivo stimulation of the kit of drug use in a hospital room (con-
text B). After discharge, when returning home (context A) and being reexposed to
the drug kit, he or she relapses, which is called renewal of response. Cunningham
(1998) suggests that a solution to this problem would be to conduct CET in as many
contexts as possible. Animal research found that, when the extinction process is
performed in multiple contexts, the effects of renewal are attenuated. Animals that
received extinction training in several new contexts and were then tested in the
original conditioning context exhibited responses indicating extinction. These stud-
ies suggest that extinguishing conditioned responses in multiple contexts increases
the generalization of extinction (Chelonis et al., 1999; Gunther et al., 1998). Despite
not corroborating with these results, studies with humans have quite inconsistent
findings, sometimes showing renewal effects, sometimes not. The fact that some
studies demonstrate no renewal effects shows that extinction can generalize to other
contexts (Barnier, 2015; Collins & Brandon, 2002; MacKillop & Lisman, 2008;
Stasiewicz et al., 2007; Thewissen et al., 2006).
In contrast to the renewal effect –which occurs when changing contexts—spon-
taneous recovery happens due to the time elapsed between extinction training and
reexposure to CS in the very context in which the pairing happened (Conklin &
Tiffany, 2002). Therefore, to attenuate the effects of spontaneous recovery, the inter-
val between CET sessions should be spaced, the number of exposure episodes to the
stimulus at each session should be reduced, as well as the exposure time between
sessions.
The reinstatement of extinct responses occurs when there is reexposure to the US
after extinction. Similar to the renewal of response –in which the emergence of
extinguished responses occurs in the presence of the CS—the reinstatement of
extinguished responses occurs in the presence of the US. Although the reinstate-
ment of responses can be extinguished more quickly with CET, this phenomenon
implies that extinguished CSs also regain a function of eliciting responses, even
when there is no pairing between US and CS after extinction. In other words, small
substance doses reinstate extinguished physiological responses and the eliciting
function of CSs for these responses. (from de Wit & Stewart, 1981).
Therefore, when a CS elicits a CR similar to an UR, it can elicit CRs that resem-
ble the effect of the substance itself and promote renewal of self-administration or
drug-seeking responses, just as small doses of the substance reinstate
102 R. N. M. Montan and R. A. Banaco

self-­administration after extinction (de Wit & Stewart, 1981). Individuals may have
contact with small doses of the substance indirectly by taking medicine that con-
tains a small amount of the substance or produce analogous effects. For example, an
individual with alcohol use disorder who has reached extinction of CRs through
CET, and is abstinent for 3 months, free of craving either in the presence or absence
of alcohol environmental cues, when in contact with a cough medicine (containing
alcohol), may reinstate extinguished responses. Now, when in the presence of alco-
hol CSs, they may relapse. Any analogous substance to alcohol –such as anxiolytic
drugs—may be enough to reinstate extinguished responses as they have similar
effects to those of alcohol on the gabaminergic system (Mellentin et al., 2017).
Taking into account the effect of reinstatement of responding, we must consider that
CET is not recommended for patients whose goal is to reduce alcohol or any other
substance intake to a moderate level, but rather to those patients who aim to achieve
abstinence.
A promising study outlines a procedure that intervenes on memory reconsolida-
tion (in behavioral terms: responding again to CSs) thus producing an attenuated
effect over the reinstatement, renewal, and spontaneous recovery of extinguished
responding. Heroin users who had their memory of heroin cues reactivated by CSs
10 min before extinction sessions exhibited a long-lasting learned extinction of dia-
stolic and systolic blood pressure responses. The attenuation of responding was
observed when heroin CSs were presented again after 30 days and 6 months (Xue
et al., 2012).
There is an implicit assumption in the CET paradigm that CRs either serve as
mediators for drug use, or play an important role in the interaction between respon-
dent and operant behaviors. If CRs do play an important role in substance use,
extinction-based treatments should be effective to eliminate it. However, substance
use also involves operant conditioning in addition to respondent. Not only do drug
CSs have an eliciting function, they also evoke operant responses. In other words,
they can have an OM function for self-administration of the substance by removing
or attenuating aversive CRs. The extinction process may fail to extinguish the con-
trol of certain dimensions of the stimulus over respondent responses. This condition
would maintain the motivating aspect of establishing the removal of CRs as rein-
forcing. If this removal consists of being the greatest reinforcer available in the situ-
ation, there will be failure to extinguish CRs to stimuli that are not so salient (the
new learning), thereby threatening the extinction training. For example, a bottle can
have both the function of a CS and an OM. If CET only extinguishes CRs related to
the bottle, without the operant response of drinking becoming extinct (due to the
positive effects of alcohol being the only alternative for well-being in a social situ-
ation), then drinking will remain intact and some stimuli that are still salient in the
contingency will continue to have a discriminative function –in our example, the
social situation (Conklin & Tiffany, 2002). If the act of drinking is not extinguished
or replaced, for example by social skills training, CR extinction is likely to be insuf-
ficient to eliminate drinking (Banaco & Montan, 2018).
In the classic conditioning model, CET should result in habituation or extinction
of CRs, enough to be generalized to real life environments (Monti et al., 2002).
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 103

However, the generalization of extinction may not occur between the CSs used in
the treatment and those present in the natural environment (Thewissen et al., 2006;
Barnier, 2015; Kim et al., 2015). As a result, the real-life environment may continue
to exert control over drug CRs, which determines that operant substance use is nega-
tively reinforced by removing CRs. Social learning theory states that patients must
practice coping skills during CET so that they are trained to emit, in the presence of
drug CRs, responses that produce consequences that compete with the reinforcing
effect of the substance (Rohsenow, Rohsenow et al., 1995). Some studies have iso-
lated CET procedures by focusing on exposure to CSs without developing skills to
cope with urges (Park et al., 2014). Other studies performed urge-specific coping
skills training combined with CET and observed that the skills taught during CET
are correlated with reduced substance use (Marlatt, 1990; Monti et al., 1993; Monti
& Rohsenow, 1999; Rohsenow et al., 2001). Therefore, Monti et al. (2002) renders
it important to combine CET and urge-specific coping skills training, both for habit-
uation or extinction of CSs and for practicing skills that can be used outside the
clinical setting, in an event of renewal, reinstatement, or spontaneous recovery of
CRs extinguished during CET.
Current SUD treatments and other therapeutic interventions in general can be
unsuccessful as they present methodological issues. Within the model of behavior
therapy, sessions usually last around 1 h and focus on the functional analysis of
substance use, offering conditions for the client to have contact with the variables
that maintain the target behavior in light of the respondent and operant conditioning
theory. The use of functional analysis to understand the variables that maintain sub-
stance use is indispensable for the development of effective interventions. However,
the psychotherapy session can take place in a clinical outpatient setting or inpatient
voluntary, involuntary, or compulsory hospitalization. Regardless of the therapeutic
setting, the patient is treated in the absence of the substance and its CSs. Marlatt
(1995) thus poses the question: if behavioral interventions based on conditioning
theory comprise the interaction between stimulus and response, the most obvious
question to be asked is: where is the stimulus? If substance use is the target behav-
ior, why are the stimuli conditioned to its use and context absent in SUD treatment?
Instead of exposing patients to stimuli conditioned to the context of use in order to
prepare them for inevitable situations that elicit and evoke its use outside the clinical
context, the individual ends up being treated in the complete absence of any CSs.
The clinical setting –especially hospitalization—is rid of any stimuli that signals the
presence of the substance, configuring a protective shield, which keeps the patient
away from any stimulus that causes “temptation,” often referred to as the “forbidden
fruit.” A patient who is treated in these conditions receives little preparation to face
exposure to stimuli outside the clinical context.
Regardless of whether the patient’s objective is abstinence or decreased use to a
controlled pattern, leaving this client unprepared without previous experiences to
any type of stimulus exposure increases the chances of relapse. CET still requires a
functional analysis of substance use and must be complementary to other therapeu-
tic approaches, thus preparing the patient to effectively cope with daily reexposures
to high-risk situations that can lead to unwanted relapses.
104 R. N. M. Montan and R. A. Banaco

Final Considerations

SUD is a complex phenomenon widely debated in different therapeutic approaches.

This chapter addresses the theoretical and empirical bases, as well as possible clini-
cal implications of a model that emphasizes respondent conditioning and its role in
substance use and dependence, while also considering the interaction between
respondent and operant processes. Pavlovian conditioning and its mechanisms on
substance use produce physiological changes (CRs) that can be measured in the
presence of CSs even though in the absence of the US (drug). Drug CSs produce
CRs that can occur either in the same or in the opposite direction as the effect of the
substance (UR). The factors that determine the relationship between CRs and URs
are still unknown, but it is already known that they are not determined by the class
of the drug. When it occurs in the same direction as URs –that is, the CS produces
similar responses to those of the US— the CRs produce motivational states that
establish the effect of the substance as a positive reinforcer. When it occurs in its
opposite direction, the CS produces aversive physiological states that establish the
effect of the substance as a negative reinforcer. Many theorists understand that these
aversive physiological states are compensatory CRs that “protect the organism”
from the harmful effects of the substance, and that this same compensatory action is
responsible for tolerance, withdrawal, craving, and overdose. According to this the-
ory, relapse and active drug-seeking, after long periods of abstinence, have been
understood as an effect caused by the reexposure of the individual to drug CSs that
have the ability to elicit and evoke responses that increase the motivational state for
drug-seeking.
The clinical implications of this theoretical model guide CE studies –a method of
assessing responses in the presence of stimuli—and CET studies –an intervention
method on drug CRs. CE is a procedure that exposes substance users to a variety of
drug cues, while self-report and physiological responses of craving are monitored.
CET, however, proposes an intervention whose goal is to extinguish the pairing
between CSs to the drug, hence without presenting it as a US, thus avoiding CRs to
CSs. The rationale for this approach explains that repeated reexposures to CSs in the
absence of substance intake (UR) should eliminate the CRs elicited by CSs, and
thus eliminate physiological states that influence active drug-seeking. However,
some factors interfere with the generalization of learned extinction and its mainte-
nance over time. Some effects can cause the responses extinguished through CET to
return, these being the effects of renewal, reinstatement, and spontaneous recovery
of extinguished responses. Failure to extinguish some stimulus properties may also
occur, such as motivating aspects that evoke operant responses that are reinforced
by the effect of the substance. To prepare individuals for possible reappearances of
CRs after treatment, authors have suggested combining CET with urge-specific
coping skills training. This combination would allow users to experience the bene-
fits of coping skills when experiencing decreases in drug CRs during its practice,
with the aim of generalizing these skills outside the clinical setting. In any case,
CET should be conducted in protected environments that can ensure the prevention
8 Cue Exposure Therapy for Substance Use: A Complement to Functional Analysis 105

of substance use between training sessions. In outpatient settings, the patient may
suffer relapses between sessions, so the implementation of methods –such as help
from the family or a therapeutic monitoring team—can be essential when CET is
applied outside the hospital setting.
CET consists of a complementary technique to the clinical practice of behavior
analysts who want to intervene on the interaction of respondent and operant pro-
cesses observed in the acquisition and maintenance of substance use and depen-
dence. Factors that threaten the extinction process should be the focus of researchers
who study new parameters of the technique in search of new discoveries, both
through controlled observations of applications and experimental studies.

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Chapter 9
Functional Analytic Psychotherapy (FAP)
as an Adjunct Treatment to Substance
Dependence Cases

Alan Souza Aranha, Claudia Kami Bastos Oshiro, and Elliot Cozzens Wallace

Introduction: Functional Analytic Psychotherapy (FAP)

FAP is a psychotherapy based on the philosophy of radical behaviorism and the

conceptual aspects of behavior analysis (Kohlenberg & Tsai, 1991; Skinner, 1945,
1953, 1957, 1974). FAP intends to develop the client’s interpersonal repertoire,
making them more capable of producing positive reinforcement and eliminating
aversive stimuli in its social context. To accomplish this goal, FAP therapists pro-
pose that the psychotherapeutic relationship be used as (a) a source of additional
information about the client’s behaviors and (b) a mechanism for clinical change
(Tsai et al., 2009).
The authors of FAP argue that a portion of human suffering occurs as a result of
problems in interpersonal repertoire: contact with the social environment evokes
problematic patterns of interaction, either with an increase in aversive stimulation
density or in the scarcity of positive reinforcers. The individual seeks a psychothera-
pist in order to receive assistance to feel better and because it is a social relationship,
the deficits and excesses presented in the individual’s daily life are generalized to
the psychotherapeutic relationship. This is the ideal scenario to evaluate the client’s
repertoire and strengthen more effective behaviors in-session. When the client
establishes a healthier relationship with the professional, generalization strategies
can be outlined so that the therapeutic progress are transposed to the out-of-session
context and the individual establishes healthier relationships with his or her peers
(Kohlenberg & Tsai, 1991).

A. S. Aranha () · C. K. B. Oshiro

University of São Paulo, São Paulo, SP, Brazil
e-mail: [email protected]
E. C. Wallace
University of Washington, Seattle, WA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 109
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_9
110 A. S. Aranha et al.

There is a classification of possible therapist and client behaviors that occur in an

FAP therapy session. Regarding the client’s behaviors, the main ones are named
clinically relevant behaviors (CRBs). A CRB1 is a behavior that occurs in-session,
which is functionally similar to the out-of-session problem behavior; CRB2 is a
therapeutic progress; and a CRB3 is a verbal report of the client’s behavior and the
variables of which is a function. The description of the client’s own behaviors and
the contingencies of reinforcement that control them help the client to emit the skills
learned in the presence of the psychotherapist in situations that evoke his or her
problem behaviors outside the session (Kohlenberg & Tsai, 1991).
It is important to clarify the relationship between CRBs and out-of-session prob-
lem behaviors. Both behaviors are perceived as part of the same response class,
defined as responses that produce the same consequences, regardless of their form
(Catania, 1998/1999). A person can eat using a fork and knife, spoon, or with his
hands. All topographies would be in the “lunch” response class, as they produce the
“food” consequence. The difficulties of the client must be understood in the same
context. The psychotherapist may identify that the client’s problem behaviors are
associated with the aggressiveness with which he addresses people (e.g., offending,
increasing tone of voice), but should not expect the client to emulate similar topo-
graphic behaviors in-session (e.g., expressing offenses or increasing tone of voice
toward the psychotherapist). Firstly, the therapist should understand the function of
the aggressiveness – to cause harm, to draw attention, to avoid – and then hypothe-
size which responses may contain the same function in therapy. There are several
possible topographies to annoy, call attention to, or avoid professional’s
interventions.
Regarding the therapist’s behaviors, the Five Therapeutic Rules are instructions
on how the clinician should behave in-session to assist his client. They are a system-
atization of the functional analysis for the therapeutic relationship (Kohlenberg &
Tsai, 1991; Tsai et al., 2009): (1) observe the emission of CRBs, (2) evoke CRBs,
(3) contingent responding to CRBs, (4) evaluate the intervention, and (5) program
the generalization of behaviors.
Rule 1: The first rule refers to the activity of identifying CRBs (Tsai et al., 2009).
In the case conceptualization stage, it consists of the psychotherapist observing
and relating the client’s behaviors that occur in-session with the problem behav-
iors that occur outside the session. Briefly, three questions can be raised:
1. How can problem behaviors both described by the client and identified by the
therapist be generalized to the context of the session?
2. How do the observed CRBs occur in the client’s daily life?
3. What are the functions of these behaviors? Or what are the antecedents and con-
sequences of all the behaviors of the response class, inside and outside the
session?
In the intervention, with the knowledge of the function of the CRB1s, Rule 1 pro-
poses to pay attention to the CRBs and to proceed with the other rules. If the profes-
sional is not under control of the relevant behaviors of the client that occur in-session
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 111

(under control of not very relevant behaviors or the topography of the CRBs), he
will face challenges in managing them therapeutically.
Rule 2: CRBs may occur in-session due to the social nature of the psychotherapeu-
tic relationship (by processes of generalization and stimulus equivalence). A per-
son who behaves according to the demands of the social group to avoid the
negative evaluation (e.g., using a psychoactive substance to not be disapproved),
is likely to be under control of the possible negative evaluations that the psycho-
therapist has about such individual in-session (e.g., following the therapist’s
requests to change the time of the meeting, agreeing with the therapist’s analy-
ses). The professional may also manipulate different events in order to intention-
ally evoke the CRBs, as mands (“could you behave in a certain way?”) (Callaghan
& Follette, 2008; Vartanian, 2017), structured exercises (Nelson et al., 2016), and
free association (Tsai et al., 2012). Rule 2 aims to increase the frequency of
CRBs in-session and the number of opportunities to apply the third rule
(Vartanian, 2017).
Rule 3: Consistent with an analytic-behavioral model, FAP holds that the behaviors
of any individual are selected for their consequences (Skinner, 1953). It is postu-
lated that Rule 3 is the FAP’s mechanism of clinical change, the therapist’s con-
tingent responding to the client’s CRBs. The professional should present aversive
consequences to weaken CRB1s (punishment, extinction), but mainly present
positive reinforcing consequences to strengthen CRB2s. The available conse-
quences are the therapist’s own actions in-session (Kohlenberg & Tsai, 1991).
It is important to stress that the psychotherapist’s behaviors are also defined by
their functions – their effects on the client’s repertoire – and not by their topographies.
The inexperienced therapist may praise his client believing that this is a “positive
reinforcement” or criticize him to “punish unwanted behavior,” but interventions have
different functions depending on the history of contingencies of reinforcement and the
CRBs identified in case conceptualization. For the individual who expresses feelings
of low self-esteem, a compliment can be an aversive stimulus (“my therapist is an
actor,” “he just wants to please me”). On the other hand, for the person who has a his-
tory of family conflicts and social isolation, criticism can have a conditioned reinforc-
ing function by pairing with attention opportunities. The professional’s criticism does
not decrease the frequency of unwanted behavior, but evokes a chain of discussions
and an increase in the frequency of the problematic pattern. It is necessary for the FAP
therapist to build intervention strategies that are sensitive to the case conceptualization
and to judge its results throughout the therapeutic process.
Rule 4: The only way to know if the case conceptualization was correct and if the
intervention had a successful repercussion is to evaluate its effects. This is
accomplished in FAP, both by asking the client directly (“what did you feel when
I explained it to you?”) and by considering the change in CRB frequency. In a
research environment, the frequency of CRBs can also be recorded with the
Functional Analytic Psychotherapy Rating Scale (FAPRS) (Callaghan &
Follette, 2008).
112 A. S. Aranha et al.

Rule 5: CRB2s built in-session should be generalized in the client’s out-of-session

relationships, the ultimate goal of psychotherapy. Generalization can be facili-
tated with homework (“you were able to express your opinions to me. What do
you think about trying to reproduce this behavior with your husband?”) and dis-
cussions about the functions of client behavior in-session (“I believe you agree
with my analysis of your fear that I will judge you. Is it similar to what you told
me about smoking marijuana so no one makes fun of you?”). FAP psychothera-
peutic model is summarized in Fig. 9.1.
Other categories of behavior can occur in FAP sessions. For example, throughout
the psychotherapeutic process the client will discuss problem behaviors and, pro-
gressively, improvement behaviors emitted outside the session (O1 and O2, outside
CRB1s and outside CRB2s). In turn, the therapist will be able to respond to these
descriptions (RO1 and RO2, response to outside CRB1s and response to outside
CRB2s). Explanations of other categories can be checked in the FAPRS categoriza-
tion system (Callaghan & Follette, 2008).
Which clients can benefit from FAP strategies? In the first book published,
Kohlenberg and Tsai (1991) argued that interpersonal problems would be the ideal
targets of psychotherapy, such as intimacy and personality disorders. Thus, it is pos-
sible to find studies discussing the application of FAP to problems in the interper-
sonal repertoire, such as borderline personality disorder (Oshiro et al., 2012),
histrionic personality disorder (Callaghan et al., 2003), oppositional defiant disorder
(Xavier, 2018), and social anxiety (Lovo, 2019). In the same period, authors
described FAP application for other clinical conditions, such as major depression
(Kanter et al., 2006), posttraumatic stress disorder (Lima, 2017), obsessive-­
compulsive disorder (Vandenberghe, 2007), and panic disorder with agoraphobia
(Pezzato et al., 2012). One of the psychiatric conditions studied in recent years was
substance dependence, which is discussed in this chapter.

Fig. 9.1 FAP psychotherapeutic model. Adapted from “Psicoterapia Analítica Funcional.
Functional Analytic Psychotherapy (FAP)” by Oshiro (2014). Instituto de Terapia Cognitiva
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 113

Substance Dependence

The psychopathologies described in mental health diagnostic manuals, such as the

International Classification of Diseases (WHO, 2018) and the Diagnostic and
Statistical Manual of Mental Disorders-5 (APA, 2013), are conceptualized by
behavior analysts as respondent and operant responses in the individual’s repertoire.
These psychopathologies are differentiated from other behaviors only by the harm
they cause to the social environment and to the person who behaves (Banaco et al.,
2010; Vilas Boas et al., 2012). The analytic-behavioral therapist is interested in
describing all the behaviors that contribute to the repertoire classified as psycho-
pathological, identifying the contingencies that maintain these behaviors and pro-
posing strategies to change them (Banaco et al., 2012).
In this regard, it is worth mentioning an example of the functional analysis of
depression provided by Ferster (1973). The author described that among the
responses that would characterize the depressive pattern, the following stand out:
reduction in performance (decrease in the frequency of activities that produce posi-
tive reinforcement and eliminate aversive stimulation), excessive ineffective escape
behavior (they do not remove aversive stimuli from the environment, keeping the
subject in contact with the stimuli), and “bizarre and irrational” behavior (rituals
and stereotypes). Contingencies of reinforcement that maintain depression would
be difficulties in discriminating the environment (not evoking adequate responses to
produce positive reinforcement and eliminate aversive stimulation), unfavorable
environment for the development of effective behaviors, reinforcement schemes
that require high frequency of responses (leading to extinction and inactivity),
changes in the environment (absence of antecedents that evoke the available reper-
toire), and emotional changes that compete with operants (decreasing access to
positive reinforcement). In the light of the above, the main goal of the treatment
would be the construction of an appropriate repertory to manipulate the present
contingencies, removing the client from the depressed and stereotyped condition.
One purpose of psychotherapy would be to refine the verbal description of the client
about the environment, improving his discrimination of relevant antecedents that
would consequently evoke positive and negative reinforced responses.
In order to understand substance dependence, it is first necessary to operation-
alize the relationship between the individual and the drug into respondent and
operant components. Two important respondent phenomena are the withdrawal
syndrome and tolerance. A psychoactive substance has the function of an uncon-
ditioned stimulus (US) that elicits two unconditioned responses (UR), its pharma-
cological effect and the compensatory responses that reestablish the homeostasis
of the organism (e.g., when administering heroin, the user feels a decrease in
sensitivity to pain and later an exaggerated sensitivity to pain). Friends, places of
use, feelings, etc. (NS, neutral stimuli), are paired and acquire conditioned func-
tion (CS) for aversive compensatory conditioned responses (CR), the withdrawal.
Contact with CS elicits unpleasant physical symptoms and the user experiences
craving to use again. When the drug is consumed in the same or similar
114 A. S. Aranha et al.

environments, a new respondent conditioning occurs (US-CS pairing) and, conse-

quently, abstinence syndromes perpetuate over time. Tolerance occurs when the
user administers the drug in contact with the previously conditioned CSs and,
with the compensatory effects present, the effect of the drug is smaller. The indi-
vidual begins to demand increasing amounts of the substance to achieve the
desired effects (Benvenuti, 2004, 2007; Siegel, 2005).
In an operant contingency, substance consumption is evoked by antecedents
(discriminative stimuli and reflexive establishing operations) and selected by con-
sequences (positive and negative reinforcement). In the context of being in a bar
with peers (physical and social discriminative stimuli), drinking alcohol can lead
to drunkenness (positive pharmacological reinforcement) and group attention
(positive social reinforcement). The use of alcohol can also be solitary (besides
the pharmacological effect, it can have a conditioned function by pairing between
alcohol and social reinforcement). Difficulties that the client experiences and
withdrawal syndrome (aversive stimuli as antecedent) may lead him/her to con-
sume substances to temporarily reduce contact with these stimuli (negative rein-
forcement). Private events such as feelings and thoughts are paired with the
original aversive stimuli and begin to evoke escape-avoidance behaviors (condi-
tioned aversive stimuli as antecedents) (Borloti et al., 2015; Higginset al., 2007;
Miguel et al., 2015).
Most of those who administer drugs themselves are sporadic or occasional users
who do not produce serious consequences for themselves and others (Laranjeira
et al., 2014), which is essential to label consumption as psychopathological (Banaco
et al., 2010; Vilas Boas et al., 2012) (for a list of consequences of substance abuse,
see Tonigan & Miller, 2002). The basic processes explain certain situations where
use brings harm. For example, withdrawal syndrome can be a relevant variable for
consumption to become harmful; the unpleasant physical symptom evokes escape
responses to eliminate such state, negatively reinforcing the use. At the same time,
the contact between the substance (US) and the environment (CS) maintains the
respondent conditioning and, consequently, the withdrawal on future occasions. The
very behavior that removes the syndrome allows it to perpetuate, sustaining the
cycle of abuse (Banaco & Montan, 2018). However, it is worth noting that this is
only one of the possibilities for a dependent pattern to manifest itself. The existence
of the abstinence syndrome is not essential for the use of the substance to become
pernicious (APA, 2013; Higgins et al., 2007; Rush et al., 2019).
Researchers study which other possible variables, besides the respondent condi-
tioning associated with escape-avoidance behaviors, influence a portion of the pop-
ulation to develop relevant compulsion (Bernardes, 2008; Garcia-Mijares & Silva,
2006; Heyman, 1996; Wilson & Byrd, 2004). Another critical variable for the devel-
opment of substance dependence is when a person who exhibits excess behavior
under control of short-term consequences at the expense of long-term consequences
may experience problems with their consumption (APA, 2013; Higgins et al., 2007;
Madden & Bickel, 2010). In a context where the client may emit two responses that
produce different reinforcers – smoking marijuana to “relax” or studying for the
vestibular at the end of the year – he will probably emit the behavior that produces
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 115

immediate consequences. Even in contact with aversive consequences (e.g., losing

the school year, not starting a professional life), the user will continue to emit short-­
term responses (e.g., smoking) at the expense of the long term (e.g., studying).
Problem-solving (Moos, 2007; Silva & Serra, 2004; Wilson & Byrd, 2004), frustra-
tion tolerance (Guilhardi, 2010/2013, 2018; Marlatt & Donovan, 2009), and sensi-
tivity to the consequences that he/she produced to others (Costa & Valerio, 2008;
Guilhardi, 2010/2013, 2018) are some repertories that, when little or badly elabo-
rated, can facilitate the progression of the psychopathology.
Both deficits and excesses in the interpersonal repertoire that the client manifests
are risk factors that can lead to substance dependence (Aranha & Oshiro, 2019;
Marlatt & Donovan, 2009; Wilson & Byrd, 2004). A young person may feel judged
by his friends, not have many day-to-day activities, and suffer due to family con-
flicts. Drug use would decrease his sensitivity to criticism (making him neutral or
less aversive), give him something to do when he is idle (e.g., smoking marijuana
alone), and guarantee him a tool to forget the problems he experiences at home (e.g.,
sniffing cocaine and being more under control of pharmacological effects than fam-
ily contingencies). The reinforcement promoted by the substance strengthens the
use behavior and marks the antecedents as evocative stimuli. In situations with simi-
lar difficulties, planning, search, and use behaviors occur and are again reinforced.
The cycle decreases the space for the client to learn how to deal with the problems
and, as a result, makes him/her more and more dependent on the substance (Banaco
& Montan, 2018; Holman et al., 2012; Ribeiro & Laranjeira, 2012). Psychotherapeutic
intervention focusing on interpersonal repertoire would provide access to new
sources of positive social reinforcement (e.g., expressing feelings, creating inti-
macy), physical reinforcement (e.g., meeting groups with interests in games and
sports), and escape-avoidance behaviors (e.g., seeking help, dealing with criticism).
The antecedent that evoked unwanted responses will now evoke alternative
responses that will be progressively consolidated in the client’s repertoire, moving
him away from drug use (Aranha & Oshiro, 2019; Gifford et al., 2006; Holman
et al., 2012; Rachlin, 1997).
For clients who suffer from withdrawal syndrome, interpersonal intervention
promotes important complementary improvements. The same antecedents that
evoke the use have conditioned stimuli function (CS) that elicit the syndrome. When
the subject is exposed to these stimuli and emits alternative behaviors instead of
consuming the substance (US), the process of respondent extinction occurs, making
the unpleasant physical symptoms less and less intense (Gifford et al., 2011; Holman
et al., 2012).
FAP is a behavioral psychotherapy whose goal is to develop the interpersonal
repertoire of clients. It uses the therapeutic relationship as a source of information
to perform case conceptualization and as a mechanism for clinical change when the
therapist presents differential consequences for relevant behaviors (Tsai et al.,
2009). FAP can be used as an adjunct treatment for substance dependence, since
there is a chance that substance dependents have deficits and/or excesses in the
interpersonal repertoire that inhibit access to reinforcers and keep them in contact
with aversive stimulation of social origin. The repertory restriction helps in the
116 A. S. Aranha et al.

installation and progression of dependence (it increases the frequency of substance-­

consuming behaviors) and intensifies interpersonal problems (it decreases the
opportunities for learning effective repertories). When deficits and excesses become
generalized in the relationship with the psychotherapist as CRB1s, the psychothera-
pist can use the FAP to model more effective repertories, the CRB2s. The positive
reinforcing consequences not only strengthen the CRB2s but also mark the psycho-
therapist’s discriminative function for these behaviors. By encountering other inter-
personal out-of-session relationships, the psychotherapeutic progress becomes
generalized, producing new reinforcers. The strengthening of the repertoire broad-
ens the possibilities for the user to recover (Aranha & Oshiro, 2019; Holman et al.,
2012). If the client exhibits withdrawal symptoms, the respondent extinction may
also occur in-session. The psychotherapist’s behaviors have both discriminative and
eliciting functions (Kohlenberg & Tsai, 1991), causing the syndrome to continue.
When CRB2s are emitted and produce social enforcers and not drugs, there is a
break in US-CS conditioning. In addition, the operant generalization of CRBs helps
to have a higher frequency of responses that do not result in drug use outside the
session and, as a result, a higher likelihood of respondent extinction in the natural
environment (Gifford et al., 2011). FAP psychotherapeutic model for substance
dependence is summarized in Fig. 9.2.

Fig. 9.2 FAP psychotherapeutic model for substance dependence

9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 117

The Application of FAP to Substance Dependence

Articles related to FAP and substance dependence offer possibilities for the applica-
tion of psychotherapy to the population. We describe the main studies published,
emphasizing the CRBs identified, the proposed interventions, the benefits of apply-
ing the FAP within the treatment plan, and the results obtained.
Pedersen et al. (2012) presented a clinical case of a client who met the diagnostic
criteria for posttraumatic stress disorder (PTSD), dysthymia, alcohol dependence,
bulimic behaviors, and characteristics of dependent personality disorder. PTSD
symptoms (traumatic reexperience, hyperexcitability, and avoidance) were related
to a history of sexual abuse and a threat to physical integrity. The proposed treat-
ment included two steps. In the first stage, cognitive-behavioral therapy (CBT) for
substance dependence, bulimia, and PTSD was conducted, and in the second stage,
CBT was added to FAP with a focus on interpersonal difficulties.
The first phase was effective in eliminating bulimic behavior, promoting absti-
nence from alcohol, and decreasing PTSD symptoms, except for social avoidance
behaviors. Deficits in the interpersonal repertoire led the client to isolation and
relapse from alcohol use. At this time, researchers chose to add FAP to intervene in
the repertory deficits, identifying as CRB1s: difficulty in discriminating the appro-
priate context to self-disclosure, avoidance behaviors from interpersonal contexts,
and not reinforce behaviors of approaching by others. The expected CRB2s were
listed as discriminating opportunities to expose oneself emotionally, building inti-
macy by discussing positive and negative experiences, asking how the client could
behave to be more reinforcing, and reinforce the disclosure of others. The goals of
promoting CRB2s were to decrease escape behaviors and increase the participant’s
probability of obtaining social reinforcement. Instruments for PTSD symptoms and
interpersonal functioning were used. After 9 months of FAP, results of the instru-
ments ascertained that reexperience and hyperexcitability remained stable; how-
ever, the frequency of avoidance behaviors decreased and self-disclosure behaviors
increased. A clinical evaluation pointed to increased frequency and effectiveness of
social connections, abstinence from alcohol, decreased use of health services,
decreased dependence of the therapist, and increased accountability for his choices
and well-being (Pedersen et al., 2012).
Since this is not a specific study for substance dependence, Pedersen et al. (2012)
did not describe the relationship between interpersonal deficits and alcohol use. It
can be conjectured that substance abuse had two functions: in the absence of signifi-
cant social connections, as a response that produced positive reinforcement stimuli,
and, under control of the same history of PTSD symptoms, negatively reinforced
escape behavior. The development of the social repertoire increased the positive
reinforcers available to the participant, changed the aversive function of social inter-
actions and consequently decreased the frequency of drinking. The FAP strategies
were not made explicit, only the CRBs and those that were targeted for intervention.
Paul et al. (1999) conducted a research targeting deviant sexual behavior and
substance abuse. The client met the diagnostic criteria for marijuana abuse and
118 A. S. Aranha et al.

exhibitionism. Given that he was exposing himself in public, the judiciary system
ordered the client to be submitted to mandatory psychotherapy. Initially, the psy-
chotherapist investigated the sequence of events that led to the sexual pattern; when
driving and using marijuana, the client was looking for a woman he considered
attractive, which produced in him an intense desire to adopt exhibitionist behavior.
After expressing the exhibitionist behavior, he would return to his house, where he
would smoke, masturbate, and reminisce the exhibitionism event.
A functional analysis evidenced that deficits in the interpersonal repertoire would
be one of the variations for the maintenance of problematic sexual activity and drug
abuse. The client experienced anxiety when he was around women (he had never
met or had sexual intercourse with one). Exhibitionism ensured access to social
enforcers that the client would not otherwise produce, but he needed to consume
marijuana so that social disapproval would not inhibit him. The pharmacological
effect of the substance also acquired a negative reinforcement function when used
in the presence of feelings of loneliness and inadequacy (Paul et al., 1999).
The client became aware that the cycle of dependence and public exposure
brought losses in the academic and social areas, besides producing feelings of inad-
equacy and guilt. Exhibitionist tendencies and impulses became aversive (indicat-
ing that the exhibitionist behavior was imminent), but attempts of self-control failed.
“Holding on” did not modify the contingencies maintaining the problem behaviors,
leading the client to relapse. Due to attempts to control private events, acceptance
and commitment therapy (ACT) was proposed (Hayes et al., 2012), with the follow-
ing purpose: acceptance of sexually deviant thoughts and feelings, reduce the fre-
quency of exhibitionist behavior, reduce the frequency of marijuana use, and
increase social connections. Changes in intensity and frequency of impulses related
to exhibitionist behavior, episodes of exhibitionism, masturbation, and marijuana
use were recorded with self-monitoring, and symptoms of anxiety and depression
recorded with standardized inventories. In 6 months of ACT, increased connections
with women and decreased social anxiety were observed, but the results for exhibi-
tionism were insufficient. The authors decided to add FAP strategies (Paul
et al., 1999).
• Rule 1: The therapist identified that attempts of self-control outside the session
were functionally similar to the avoidance behaviors of not talking about exhibi-
tionism in-session, so these were conceptualized as CRB1s. Both were ineffi-
cient responses to minimize access to aversive stimulation (desire to express
exhibitionist behavior and report the desire for exhibitionism). The proposed
CRB2s were to acknowledge and report feelings, thoughts, and exhibitionist ten-
dencies in-session.
• Rule 2: The therapist intentionally evoked self-disclosure about exhibitionism
and addiction to marijuana.
• Rule 3: The therapist presented verbalizations with possible positive reinforce-
ment function (“I’m feeling closer to you” and “I’m enjoying getting to know
you better”) contingent the client’s self-disclosure. Later, he started to reinforce
any self-disclosure. The goal was to improve social skills and increase the prob-
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 119

ability that the new repertoire would become generalized in the client’s relation-
ships with third parties.
• Rule 4: It served the purpose of recognizing the effect of the intervention on the
client’s repertoire. Upon 1 month of FAP treatment, the client revealed that he
was using marijuana on a daily basis and committed to reducing the frequency.
• Rule 5: Whenever possible, the therapist would describe the CRB1s in relation
to the client’s learning history and the parallel between disclosure oneself in-­
session and accepting private events outside the session. It was also discussed
how smoking marijuana facilitated him to manifest exhibitionist behavior.
As a result, the frequency of exhibitionist urges decreased from an average of
four/five impulses to two per week, masturbation decreased from seven to three
times per week, with changes in the content of the fantasies (he stopped imagining
the exhibitionist behavior), and smoking marijuana decreased from seven to 4 days
a week. In the 6-month follow-up, the urges to express exhibitionist behavior
occurred twice a month and the use of marijuana once a week. Finally, his stage of
anxiety and depression were no longer at the clinical level, there was a possible
generalization of CRB2s with a greater social connection in the academic context,
and the client began to date a girl.
The study by Paul et al. (1999) demonstrated how the principles of FAP can be
included in complex clinical cases involving drug abuse. In the context of clinical
private service, clients with severe difficulties and in multiple areas are more the
rule than the exception (Kazdin, 2008). FAP was helpful for the therapist identify
target behaviors that occurred in-session and intervene on them, producing encour-
aging results.
Gifford et al. (2011) studied how behavioral therapies could enhance the results
of drug treatment for harmful tobacco use. Two groups received 10 weeks of the
bupropion antidepressant; however, pre-established ACT and FAP strategies were
added to the experimental group. Psychotherapies occurred weekly, with one group
meeting and one individual meeting. The ACT intervention consisted of accepting
unpleasant physical symptoms (abstinence syndrome) that increased the probability
of relapses. The application of FAP aimed to create circumstances within the thera-
peutic context for unpleasant physical symptoms to be evoked (Rule 2), effective
avoidance behaviors under the control of aversive stimulation (asking for help
instead of smoking, accepting physical symptoms) to be reinforced in-session (Rule
3), and discussing how tolerating aversive stimulation in-session was functionally
similar to tolerating aversive stimulation out-of-session (Rule 5).
The researchers recorded changes throughout the process and in post-treatment.
Process measurements were symptoms of nicotine abstinence, mood swings, expe-
riential avoidance, acceptance, and therapeutic relationship; and the outcome
records included client satisfaction and objective measurement for nicotine. The
data pointed to a higher proportion of abstinence after the intervention and at the
12-month follow-up for the experimental group and that the underlying hypothe-
sized processes (acceptance and therapeutic relationship) were responsible for the
change. Such study conducted by Gifford et al. (2011) provided more robust results
120 A. S. Aranha et al.

Fig. 9.3 FAP psychotherapeutic model for substance-dependent clients who manifest withdrawal
syndrome

on the relationship between interpersonal interventions focusing on the therapeutic

relationship and improvement regarding substance consumption. FAP psychothera-
peutic model for substance-dependent clients who manifest withdrawal syndrome is
summarized in Fig. 9.3.
Holman et al. (2012) conducted a study with the purpose of integrating empiri-
cally validated treatments for depression and smoking with FAP strategies. The
intervention combined behavioral activation (Martell et al., 2001), smoking cessa-
tion (Perkins et al., 2008), and ACT (Hayes et al., 2012). FAP was applied as an
opportunity to modeling behaviors that impacted depressed mood and smoking
urges; a repertoire that produced positive social reinforcement was incompatible
with depressed and nicotine-dependent behaviors. Five participants received 24 ses-
sions of psychotherapy. Self-reported measures for depression, smoking, psychiat-
ric symptoms and interpersonal functioning, and objective measures for nicotine
were recorded. The results revealed that four of the five clients were exempt of the
diagnostic criteria for major depression, significantly decreased the symptoms man-
ifested, and improved interpersonal functioning. One of the clients had his diagno-
sis maintained, but his symptoms were moderately decreased and his interpersonal
functioning was increased. Three of the five patients abstained from smoking, one
presented significant changes (from an average of 13.2 to less than one cigarette a
day), and the last patient had moderate changes (a 25–50% decrease in use).
Holman et al. (2012) used a number of pre-established sessions and interventions
and only the FAP was conducted ideographically. The advantages of adding FAP to
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 121

the protocols were (a) to identify problem behaviors that could go unnoticed and not
be targets for intervention and (b) to relate them to treatment for nicotine depen-
dence. In addition to the overall results, the researchers presented how the FAP
intervention was performed and the possible progress observed.
In the first case example, the therapist identified that the client presented counter-­
control behavior when he felt obliged to perform a certain task. The escape function
seems to have been learned in a context where trusting someone was followed by
punishment. The behavior made treatment difficult, as the client had to adopt the
psychotherapist’s instructions to stop smoking. It was conceptualized that intimacy
avoidance behaviors were CRB1s, while acceptance of support and care were
CRB2s. Initially the professional discussed that the client would like to create inti-
macy with people, but was afraid and ended up preventing this relationship (Rule 5).
Later, he actively promoted CRB2s assisting the client to divide the number of ciga-
rettes he would consume during the week (to progressively decrease consumption)
and direct recommendations to perform activities for the therapist and not for him-
self (influencing the client to “do for the other”). As a result, the client complied
with part of the smoking cessation protocol and felt that the therapist was “on his
side” – a feeling that usually did not emerge in his relationships.
The second client presented difficulty expressing his needs due to the fear of
causing conflict or disappointment. Asking for help in difficult situations is a signifi-
cant behavior in the treatment because the individual ensures access to social rein-
forcers instead of the pharmacological effects of nicotine. Thus, requests made
in-session were considered CRB2s. During one session, the client requested if he
could postpone the day of his last cigarette since he had been through a stressful
week. Would this be considered an escape behavior to keep smoking (CRB1) or a
cry for help (CRB2)? The therapist used the case conceptualization and understood
the response as an example of self-knowledge and expression of needs. The profes-
sional reinforced the behavior by stating that “the client knew the right moment to
stop smoking.” As a result, the client quit smoking weeks later and a possible gen-
eralization occurred when he was more assertive with his family.
Previous research provided relevant data on the use of FAP for substance depen-
dence, but methodological issues made it impossible to state the exclusive impact of
psychotherapy on this population, since it was applied in conjunction with other
therapies and there was no record of behaviors in-session (the studies recorded drug
abuse and reporting on symptoms). In this regard, Aranha et al. (2020) intended to
evaluate the isolated effect of the FAP and its hypothesized mechanism of clinical
change (the therapist’s contingent response to CRB2s) for substance dependence. A
single-case A/A + B quasi-experimental was proposed, where A = analytical-­
behavioral therapy strategies (Meyer et al., 2010), prioritizing the analysis of exter-
nal contingencies of reinforcement to the session, and B = FAP, prioritizing the
modeling of CRBs. 20 sessions were recorded and transcribed for participant 1 and
18 sessions for participant 2. The FAPRS instrument (Callaghan & Follette, 2008)
was applied to categorize the behaviors of two therapist–client dyads into 5 sessions
at each stage, and there was record of drug abuse 3 months before and 3 months
after the procedure. Clients were assisted at a voluntary admission clinic, which
122 A. S. Aranha et al.

included medical consultations, lectures on chemical dependence, cognitive-­

behavioral psychotherapy, psychoanalytical group therapy, alcoholic/narcotics
anonymous group meetings, family group counseling, and physical exercises. FAP
sessions were applied individually, focusing on modeling CRB according to case
formulations.
The first participant was diagnosed with alcohol use disorder and sought help for
“fights with relatives.” In reality, other areas of his life were also affected: unem-
ployment, expulsion from his parents’ home, conflicts with his sister and son-in-­
law, distance from friends, and 20 years without romantic relationships following
his divorce. It caught the psychotherapist’s attention (Rule 1, observe CRBs) that
the client did not express his feelings and opinions (CRB1s). The same behavior
occurred with the other professionals (“he is very closed off”) and with his daughter
(“I would like my father to talk more”). It was hypothesized that the deficit in the
repertoire minimized his access to social and emotional reinforcers and increased
the alcohol reinforcer value (Heyman, 1996). The therapeutic goals outlined were to
express feelings and opinions (CRB2s). The vignette illustrates how the psycho-
therapist strengthened the client’s CRB2s in-session:

T: And what did you feel at the time? (Rule 2, intentionally evoking CRBs).
C: Well, I was very upset with myself, hurt. Just my daughter, who has always
fought, is always fighting, always, you know… it’s… doing everything for my
good, for my well-being… and there comes a point that says, “I got tired.
Enough of causing trouble.” I have to walk with my own legs, I have to become
aware of everything I’ve done, of all the results I’ve brought to myself and to
people (CRB2, express feelings and opinions).
T: Can I say something I feel now?
C: You may.
T: In these sessions that we’re talking, that we’ve been talking about certain
issues, talking about your family, we also talked about certain strategies on
not drinking again, we talked about your new house. But it’s the first time I
feel that you talk with emotion about a subject. I mean, with a very real emo-
tion, a very real emotion… I can feel it, I can feel you talking about the impact
that your daughter had telling you “I can’t stand it anymore.” While you are
telling me about it, it is possible to see that impact here in session. You’ve even
changed your countenance a bit (Rule 3, positively reinforce CRB2).

The second participant was diagnosed with cocaine use disorder and sought hos-
pitalization for the consequences that cocaine and crack caused in his professional
routine. A change was identified in the client’s pattern of consumption depending on
his marital status. When single, (a) he increased drug use and (b) opted to smoke
crack over sniffing cocaine. The psychotherapist sought to understand which prob-
lems in the interpersonal repertoire decreased the probability that his relationships
would remain stable and intensify dependence. He observed that the client was in
9 Functional Analytic Psychotherapy (FAP) as an Adjunct Treatment to Substance… 123

conflict with professionals at the clinic for not understanding their intentions (for
example, resocialization should occur at lunch time with his family, but he should
return before night falls. The client was irritated with the imposition). The client had
difficulty in establishing relationships between the behavior of others and the con-
tingencies of reinforcement. Functionally similar behavior occurred in-session
(CRB1s) when he reported not understanding his spouse’s complaints. In fact, the
client performed certain tasks at home, ended up going out with friends and over-
loading his wife. More conflicts were caused and increased the probability of
cocaine/crack use. This excerpt exemplifies how the researcher modeled the estab-
lishment of more effective relationships between events in-session (CRB2s):

T: I mean… let’s start backwards. What do you think would justify, from a
[professional] point of view, not letting someone out [in re-socialization]? Not
that she won’t let… she does, but you must to come back. Goes out and return
(Rule 2, intentionally evoking CRBs).
C: She made this decision because I think it was made in the meeting here,
with all the members, i.e., the whole team there (CRB2, the client relates the
behavior of the professional with a discussion between professionals).
T: Maybe (Rule 3, positively reinforce CRB2).
C: Then, just like that, it’s gone. Then I picked it up and talked like this… I
started to think: “the guys are going out so much, not getting in trouble or
anything like that,” there is a limit, I think, but each case is a case (CRB2, the
client discriminates the individual reasons he can go out to lunch and come
back, while other residents can’t go out or can go out and come back the other
day etc.).
T: That’s it: each case is different, but let’s look at what possibly led [a profes-
sional] to do that. She has a lot of experience (Rule 3, positively reinforcing
the previous behavior and Rule 2, evoking new relationships between events).

The results indicated that the introduction of FAP, specifically the therapist’s contin-
gent responding to CRB2s, followed the progress and there was a decrease in sub-
stance consumption for both participants. Participant 1, who stayed longer in
psychotherapy, obtained maintenance in the frequency of CRB2s and lower rates of
drug use in the follow-up. The study provided by Aranha et al. (2020) strengthened
data from previous research on the relationship between the FAP intervention and
changes in use patterns and, most importantly, explained that the relationship is
likely to be achieved due to changes in the frequency of CRBs in-session. For a
detailed description of the case conceptualizations, refer to Aranha (2017) and
Aranha & Oshiro (2019).
124 A. S. Aranha et al.

Final Considerations

The goal of this chapter is to describe the FAP model to substance dependence and
the evidence of its efficacy and effectiveness. Since substance dependents have dif-
ficulties in interpersonal repertoire that increase the frequency of drug use, FAP
intends to develop the interpersonal repertoire of clients, using the therapeutic rela-
tionship as the main vehicle for change. When the user’s problem behaviors become
generalized in the session, it is possible to model more effective repertories and,
later on, to trace strategies of transposition to the out-of-session context. Interpersonal
progress is expected to decrease substance consumption. The description of FAP
conceptual framework for addiction and the research data were intended to promote
an additional tool for therapists who work with chemical addicts and want to
increase the chances of psychotherapeutic success.

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Chapter 10
Dialectical Behavioral Therapy (DBT)
for Substance Use Associated
with Borderline Personality Disorder

Jan Luiz Leonardi and Dan Josua

Introduction

Dialectical behavioral therapy (DBT) is an approach based on behavior analysis, the

dialectical philosophy, and Zen practice. First developed by Marsha Linehan to treat
patients with suicidal and self-injury behaviors, DBT has been recognized as a gold-­
standard treatment for borderline personality disorder (BPD) and more recently
extended to other clinical conditions such as eating disorders, substance use, major
depression, and adherence to medical treatments, in addition to being adapted to
children and adolescents with severe behavioral issues (Lungu & Linehan, 2016).
Soon after the first randomized clinical trial for patients with BPD, (Linehan
et al., 1991), Linehan began adapting DBT for a population at greater risk of early
death – patients with BPD and substance use (Linehan et al., 1999) followed by
BPD and opioid addiction comorbidities (Linehan et al., 2002). Thus, incorporating
procedures aimed at better attending people with substance use-related disorders
has been a priority in the development of DBT for at least 20 years. Such adaptation
is essential as the double diagnosis of substance use disorder and BPD ranks among
the most common in the field of mental health (Dimeff & Linehan, 2008).
To serve this population, addiction-oriented procedures retrieved from other
empirically sustained interventions were added to DBT’s standard therapeutic
structure. Thus, while keeping forms and functions of traditional treatment, DBT
for substance abuse disorder (DBT-SUD) has introduced procedures (such as toxi-
cological tests) and synthetized strategies from other well-established intervention
models (e.g., treatments focused both on damage control and withdrawal symp-
toms) (Axelrod, 2018).
As such, to better explain DBT-SUD, we must first describe an overview of stan-
dard DBT – background and rationale underlying its structure, as well as its

J. L. Leonardi () · D. Josua

Instituto de Psicologia Baseada em Evidências, São Paulo, SP, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 129
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_10
130 J. L. Leonardi and D. Josua

necessary adjustments for understanding and treating behavioral addictions. After

this introduction, we proceed to describe mechanisms specifically added to deal
with substance use disorders.

History and Philosophical Framework of DBT

DBT can be considered the product of the difficulties experienced by its developer
in applying standard behavioral therapy with patients suffering from chronic sui-
cidal ideation, multiple diagnosis, and severely impaired behavioral control (Miga
et al., 2018). When successful, DBT helps building a valuable life from the dialecti-
cal balance between two fundamental opposites – the principles of acceptance and
change (Dimeff & Linehan, 2008).
To ensure such balance, strategies from Zen Buddhism and humane psychologi-
cal traditions were added to behavioral therapy (Linehan, 1993). By observing the
effects of these oscillations –essential for effective therapeutic processes—as well
as swings between extreme behaviors of patients diagnosed with BPD, Linehan
noticed that understanding the dialectical philosophy and its therapeutic implica-
tions derived from this philosophy would be fundamental to ensure the efficacy of
DBT. To her words:
The tensions that I experienced during therapy; the need to move, to balance or synthesis
with this patient population; and the treatment strategies reminiscent of paradoxical tech-
niques that seemed a necessary adjunct to standard behavioral techniques –all these led me
to the study of dialectical philosophy as a possible organizing theory or point of view.
(Linehan, 1993, p. 30)

The dialectic philosophy, as understood by DBT, comprehends three fundamental

treatment-orienting principles. The wholeness and interrelatedness principle states
that the parts and the whole evolve from their mutual transaction, having a covariant
development. Such a concept relates to Skinner’s view on the interaction between
individual and environment, as represented by his famous quote “Men act upon the
world, and change it, and are changed in turn by the consequences of their action”
(Skinner, 1957/1992, p. 1).
The polarity principle states that seemingly opposite concepts can in fact repre-
sent two sides of the same coin. Thus, behaviors that seem dysfunctional at first
glance have an important function in extreme living conditions. To Linehan’s (1993)
words, “It was turning this idea around ‘contradictions within wisdom’ to ‘wisdom
within contradictions’—that led me to a number of decisions about the form of
DBT” (p. 33).
Finally – and possibly the most intuitive of all principles—the continuous change
states that the nature of reality itself is marked by inconstancy and novelty, not rep-
etition. This idea can be best summarized by Heraclitus of Ephesus’ famous apho-
rism: “no man ever steps in the same river twice, for it’s not the same river and he’s
not the same man.”
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 131

Therefore, we must understand that the dialectic philosophy influences DBT

both as a way of viewing the world and as a form of dialogue. In addition to adopt-
ing such principles, DBT therapists must be clear on the role of their therapeutic
stance in ensuring the conversion of these opposites –thesis and antithesis—into a
new synthesis. Thus, conflicts brought to session by BPD patients can be faced not
entirely as setbacks, but rather as opportunities to build a new reality (i.e., a
synthesis).

The Biosocial Model: Central DBT Theoretical Postulate

DBT has a central role in understanding that underneath the chaotic behaviors of
individuals with BPD lies their difficulty in finding an intermediate pathway
between over and underregulating emotional responses. (Axelrod, 2018; Koerner,
2012; Linehan, 1993, 2015). The same can be argued about suicidal (Linehan, 2015)
and substance use behaviors (Dimeff & Linehan, 2008) in the same population. It is
particularly interesting to note how the urgency in attenuating negative feelings and
low perseverance were highly predictive of BPD characteristics associated to alco-
hol abuse (Hahn et al., 2016), which suggests the relevance of emotional dysregula-
tion in the genesis of these disorders. Thus, seemingly chaotic behaviors observed
in these patients may be understood as disorganized efforts in controlling their emo-
tional suffering.
For this reason, as means to understand the biosocial model and emotional dys-
regulation, we must first understand DBT’s definition of emotion itself. According
to Linehan (2015), “are brief, involuntary, full-system, patterned responses to inter-
nal and external stimuli” (p. 6). Like some other authors (e.g., Ekman, 2004), DBT
emphasizes that emotions are determined by their survival role in evolutionary his-
tory and, as such, contains typical action patterns. To wit, emotions are as transcul-
tural as their evoking conditions, and their expression follows a predetermined
pattern. The rage we feel when witnessing a threat to someone we love is therefore
universally expressed through the same physiological responses and possibilities of
action –muscle tension and increased chances of behaving aggressively (damage
oriented).
An emotion is the result of the interaction between six subsystems: (1) emotional
vulnerability factors; (2) internal and external events that serve as emotional cues
(e.g., prompting events) (3) appraisal and interpretations of cues; (4) emotional
response tendencies (including physiological, cognitive, experiential responses, and
action urges); (5) nonverbal and verbal expressive responses and actions; and (6)
after-effects of the initial emotion (Linehan, 2015).
An example can better illustrate the interactions between these subsystems.
Imagine that, after a night of excessive drinking, John wakes up feeling nauseated
and hungover (1). When he walks into his living room, he catches sight of a pile of
beer bottles and food leftovers spread on the floor (2 – external event). He beholds
what he reckons to be chaos around him (3). His heart races and he hunches into a
132 J. L. Leonardi and D. Josua

defeat body posture (4). He starts to walk towards his bed (5 – nonverbal response)
and to think his life is broken beyond repair (5 – verbal behavior). Finally, he lies in
bed feeling exhausted and helpless (6), further nourishing the cycle of neither cop-
ing nor changing.
DBT sees emotion as the interaction between this complex group of responses,
not being isolated in any of those points. In turn, emotional dysregulation is essen-
tially characterized by five factors: (1) proneness to experiencing emotions more
intensely; (2) difficulty regulating impulsive behaviors related to strong emotions;
(3) difficulty regulating arousal involved in the emotional episode; (4) difficulty to
act according to their objectives and values when said action differs from the behav-
ioral inclination evoked by the emotion; and (5) difficulty paying attention to any-
thing other than the emotion-triggering event (Linehan, 2015). Pervasive emotional
dysregulation in turn is the inability to regulate emotions in a broad range of situa-
tions –a global pattern of emotional dysregulation that may lead to multiple
problem-­behaviors such as suicide, self-injury, and substance abuse (Koerner, 2012).
Notably, the effects that emotions have over behavior are universal –not exclu-
sive to individuals with emotional regulation deficits. For instance, after waking up
late and rushing to a meeting, most people speed in traffic, feel more frustrated with
slow drivers, and presume the number of red lights in their way will be higher than
normal. In other words, what defines a person with emotional dysregulation is not
the effect of emotions over behavior, but the intensity and frequency in which it
occurs, as well as an increased difficulty in acting upon emotional urges
(Linehan, 1993).
Thus, the biosocial model proposed by Linehan (1993) consists of the theoretical
background to describe the possible origins of such emotional regulation deficit. It
also helps to promote a scientific understanding of the phenomenon, guide the treat-
ment, and generate compassion (Linehan, 2015). The biosocial model posits that
pervasive emotional dysregulation experienced by individuals with BPD stems
from the interaction between a biological vulnerability and an invalidating environ-
ment. Here is a description of the two poles in this proposal:

The BIO in Biosocial

A good review of the evidence on biological vulnerability in the development of

BPD –as proposed by Linehan—can be found in Crowell et al. (2009). In sum, they
consist of1: genetic influence such as 5-HTT s/s, the TPH-1 gene, and the 5-HT
receptor gene, DAT-1; abnormalities in cerebral systems (5-HT, DA, HHA axis);
and a neuro limbic disorder. It is also worth noting that substance use disorder is
considered to be 30–80%.

1
5-HT stands for serotonin; 5-HTT for serotonin transporter; TPH-1 for tryptophan hydroxylase 1;
DA for dopamine; DAT-1 for dopamine transporter 1; HHA, hypothalamus-hypophysis-adrenal.
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 133

In addition to genetics, such vulnerability may stem from intrauterine factors,

physical damage to the nervous central system, or even premature learning during
brain development (Linehan, 1993). Thus, impulsivity-related genes to early trau-
mas can alter a person’s neurophysiological structure, leaving them more sensitive
to emotional stimuli. In practice, this vulnerability is demonstrated in three ways of
responding. According to Koerner (2012, p. 5):
First, people prone to emotion dysregulation react immediately and at low thresholds (high
sensitivity). Second, they experience and express emotion intensely (high reactivity), and
this high arousal dysregulates cognitive processes too. Third, they experience a long-lasting
arousal (slow return to baseline).

In other words, people with pervasive emotional dysregulation feel at lower thresh-
olds, for longer periods of time, and more intensely. Not surprisingly, the environ-
ment fails to understand their suffering, which leads to invalidation. Metaphorically,
this sensitivity to stimuli that evokes such emotions can be understood similarly to
skin burns. Just as pouring warm water onto an intact skin triggers a much different
reaction to that provoked by the same water onto a skin with third-degree burn inju-
ries, a person with this biological fragility can respond much more intensely than
people with an intact emotional skin.

The SOCIAL in Biosocial: The Invalidating Environment

Invalidating environment is an expression created by Linehan (1993) to designate a

social group that is unable to recognize individuals’ expressions of covert experi-
ences as natural outcomes of their life trajectory and genetic constitution. In this
kind of environment, such expressions are regarded as inappropriate, wrong, or
pathological. They also tend to be diminished, mocked, ignored, or neglected. In the
words of the author:
Invalidation has two primary characteristics. First, it tells the individual that she is wrong in
both her description and her analyses of her own experiences, particularly in her views of
what is causing her own emotions, beliefs, and actions. Second, it attributes her experiences
to socially unacceptable characteristics or personality traits (Linehan, 1993, p. 49–50).

When this form of communication is the general rule, individuals struggle to map
the world based on covert experiences. For DBT, emotions should serve as a com-
pass that help us interpret the world around us –all in all, they select stimuli that
stand out and increase the likelihood of this event being recorded in the future
(Barrett, 2017). When an experience is labeled as an unacceptable character trait,
individuals lose their ability to learn from these responses. People raised in a chroni-
cally invalidating environment thus start questioning their natural emotional experi-
ences, developing more rigid behavioral patterns instead (Koerner, 2012).
The invalidating environment can render people phobic of their own emotional
responses, thus worsening the problem in an attempt to escape “bad feelings.” As
the environment fails to teach emotional regulation and forces people to extreme
134 J. L. Leonardi and D. Josua

behaviors, individuals start to escalate expressions. For instance, instead of verbal-

izing their suffering or feelings of invalidation once more, they start engaging in
self-harm – such as cutting themselves – which may initially result in care, atten-
tion, etc. When self-injury stops generating the same effects, they start making sui-
cide threats, which may ultimately result in an actual suicide attempt. Vicious
escape patterns are thus consolidated, which lead to an oscillation between attempts
to eliminate emotional responses (an unreachable goal) and extreme responses
(intense and inexorable emotional crises) (Linehan, 1993).
In this context, substance abuse often appears as an attempt at emotional regula-
tion, in the absence of more skilled means of dealing with emotions. Therefore, the
function of therapy in DBT is both to block harmful emotional regulation strategies
(e.g., excessive alcohol intake) and to teach skills that can fulfill the same regulatory
function without the harmful side effects of the old pattern (e.g., emotional regula-
tion skills from DBT; cf. Linehan, 2015).

The Interaction Between BIO and SOCIAL

Linehan’s model regards the biological and social as systems in constant interac-
tion, so that the fragility on one side causes vulnerability on the other and vice versa.
Thus, an environment of extreme invalidation –where signs of child abuse are
ignored, for example—can alter a person’s neurological structure so that, through-
out life, they become more sensitive to emotion-evoking stimuli. The same is true
the other way around: children with greater sensitivity have more difficulty having
their reactions validated, precisely because they differ from the norm of a particular
family. Thus, children who are so sensitive as to feel “pain in the eyelashes” when
anxious struggle more to have their pain validated than those who simply say they
are afraid, swallow hard, and manage to get on with their day.
Whichever side the problem begins (so to speak), the question becomes impor-
tant when an interaction between the social and the biological fields starts generat-
ing a dysfunctional emotional regulation. In these cases, such interaction results in
people who failed to learn healthy self-regulation and self-care skills. Classic BPD
patients may present behaviors such as self-injury, while others start abusing sub-
stances as means of emotional regulation, leading to a BPD plus substance use dis-
order comorbidity. In this context, therapy plays the role of both reaching a
commitment to end harmful behavioral patterns and ensuring that the individual
learns new, more skillful, and relevant means to be used for the rest of their lives.

Structure of DBT-SUD

DBT states that the intervention process must serve five functions: improve the
patient’s motivation to remain in treatment and perform behavioral changes; pro-
mote the acquisition and strengthening of new behaviors; ensure the generalization
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 135

of these behaviors for relevant life contexts; help patients restructure their daily
environment so that it favors their progress; encourage the therapist to provide the
best possible intervention (Koerner, 2012; Linehan, 2015).
In standard DBT, each function is addressed by at least one form of intervention,
namely individual psychotherapy, skills training, telephone consultancy, and con-
sultancy between therapists. Importantly, forms of intervention can be adapted
depending on the implementation setting, but all functions must be present (Dimeff
& Koerner, 2007).
In the case of substance use, new elements have been added to each form. To
improve patients’ motivation to stay on treatment and make behavioral changes,
DBT-SUD includes new commitment strategies, such as scheduling regular phone
calls to check on the patient’s well-being and meeting friends and/or family mem-
bers to find and convince patients to return to treatment if contacted by the therapist.
As means to promote the acquisition and strengthening of new behaviors, skills
training includes specific content focused on substance dependence –such as dialec-
tical abstinence and the notion of clear mind (explained in further sections). In the
case of generalization of new behaviors to relevant contexts, DBT-SUD emphasizes
that the patient must be able to use new skills, even under substance effects –often
when most needed. To help the patient restructure their environment and sustain
their progress, DBT-SUD addresses the need of burning bridges and building new
ones, as well as the importance of community reinforcement. Finally, the consul-
tancy meeting –aimed at monitoring the therapist’s compliance to treatment and
motivation (cf. Sayrs & Linehan, 2019)— has been provenly fundamental, since
DBT-SUD patients commonly miss sessions, abandon therapy, and relapse to sub-
stance use, which often render professionals frustrated (Axelrod, 2018).
DBT traditionally ranks behaviors hierarchically (based on the therapist–patient
dyad) to determine the intervention sequence (cf. Linehan, 1993, 2015). This helps
to organize each session and the whole therapeutic process (especially important in
cases of multiple problems), as well as to determine behaviors subject to daily mon-
itoring throughout therapy (see below). This ranking is also important given that
substance intake can have different purposes and implications. For example, sub-
stance use as a suicide attempt differs from the one that jeopardizes the effective-
ness and continuity of treatment, or even the one that severely impairs the patient’s
quality of life but neither brings risks nor interferes with the therapeutic process.
Thus, these uses must be ranked according to their associated risks – in the exam-
ples here, a suicide attempt ranks higher in priority than uses that simply affect life
quality – which can be left for a more advanced moment in therapy.
The pretreatment phase constitutes the starting point, in which both therapist and
patient agree on a structure and outline a treatment plan –which starts to be imple-
mented more avidly on the next stage. Thus, both in standard and DBT-SUD, pre-
treatment serves to: increase the patient’s motivation; establish a 1-year
psychotherapy agreement; provide relevant psychoeducation to the case (which
includes presenting the biosocial model); explain how DBT works; and rank target
behaviors hierarchically from most to least severe (Linehan, 1993). Once these
goals are met, the patient can proceed to therapy itself, which begins at Stage 1
136 J. L. Leonardi and D. Josua

(described below) and follow a sequence that is not necessarily linear –going back
to previous stages is common practice according to the requirements of the case.
Stage 1 of standard DBT contains behaviors that (1) put the patient’s life at risk,
such as suicidal actions, self-injury, and suicidal ideation; (2) interfere with the
therapeutic process, such as being late or absent, overlooking therapeutic tasks; (3)
cause severe losses to the patient’s life quality; and (4) constitute essential but
absent components of the patient’s repertoire (severe behavioral deficits).
In Stage 1 of DBT-SUD, therapists must pay attention to possible life-­threatening
uses of the substance, such as those involving a clear suicidal intention, an ambiva-
lent possibility of death by overdose (even with no noticeable suicidal intent),
intended bodily harm (e.g., drinking with liver disease to cause further damage),
and an imminent risk according to medical evidence (e.g., doing cocaine when hav-
ing a severe heart disease). The therapist must then prioritize behaviors that inter-
fere with therapy, which includes substance use events that limit the patient’s ability
to participate or benefit from treatment –e.g., missing sessions, being unable to
learn due to intoxication, or even running the risk of arrestment due to drug use dur-
ing probation. Next on the list are behaviors that cause severe losses to the patient’s
life quality. Here, DBT-SUD employs subcategories, namely discontinue substance
use, decrease physical and emotional discomforts associated with withdrawal,
reduce cravings and substance-seeking, eliminate options (burn bridges), decrease
contact with triggers, approach stimuli whose avoidance would only be superficially
safe, and increase community reinforcement (Axelrod, 2018; Dimeff &
Linehan, 2008).
Finally, therapy must move to further, less-complex treatment stages. Thorough
descriptions of these stages can be found in standard-DBT chapters and textbooks
(e.g., Koerner, 2012; Leonardi, 2018; Linehan, 1993). They are not addressed here
as they should only be implemented after reaching stable substance use rates, there-
fore not consisting of DBT-SUD stages themselves.
Behaviors that were chosen and ranked in Stage 1 are then registered by the
patient on a daily card that must be examined at the beginning of each individual
therapy session. Roughly speaking, the card contains action tendencies on a scale
from 0 to 5, actions that occurred, use of trained DBT skills, among other relevant
information. It is traditionally filled in pencil or pen on a standardized printed sheet
(see Linehan, 2015, p. 73), but some therapists have replaced this format with cell
phone applications.

Intervention Strategies: Acceptance, Change, and Dialectics

DBT strategies are sorted into three paradigms: acceptance, change, and dialectics.
For Swenson (2016), effective DBT conduct can be described as the dance between
these three elements –most resourceful therapists would have the ability to navigate
between the principles of acceptance and mindfulness (and the Zen tradition),
change techniques from behavior therapy, and the dialectic philosophy.
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 137

Within acceptance, the main intervention techniques are (1) mindfulness –inten-
tionally and effectively observing, describing, and participating in a single activity
at the present time, free of judgment (Linehan, 2015); (2) radical acceptance –expe-
riencing a situation in its entirety without attempting to modify it; and (3) validation
stating that the way a person behaves, thinks, and feels is coherent and justified
(Koerner, 2012; Linehan, 1997). Validating includes paying attention to what the
patient is talking about, asking questions that facilitate the continuation of the
report, demonstrating an understanding of their experiences, acknowledging their
feelings, thoughts, and behaviors as an effect of their biology, their interaction his-
tory with the world, and their current context.
Linehan (1997) ranks validation strategies into six different levels and argues
that simply acknowledging the magnitude of the problem can be insufficient or, at
times, iatrogenic. Therefore, following validation strategies, the therapist must then
move towards the change paradigm and actively seek solutions to the problem. In
other words, as noted by Swenson (2016), the dance between paradigms is essential
and the excessive permanence in one can configure a risk for a satisfactory thera-
peutic development.
In the change paradigm, the therapist performs a chain analysis of the target
behavior –a step-by-step functional analysis of events that have occurred and ele-
ments that are subject to intervention (see Fig. 10.1). In brief terms, a chain analysis
first requires an objective and accurate description of the behavior (e.g., snorting 5 g
of cocaine in the bathroom at home). Then it specifies events that preceded and fol-
lowed its occurrence, namely (1) triggering event – the initial stimulus that led to
the behavior; (2) vulnerability factors –conditions of the organism that modulate the
evocative power of the triggering event, such as pain, illness, sleep deprivation,
hangover, hunger, malnutrition, and stress; (3) links –events that occurred between
the trigger and behavior, which may be the patient’s actions, thoughts, sensations
and emotions, and/or environmental events, including other people’s actions; and
(4) positive and negative consequences of the behavior, indicating whether they are
short-, medium-, or long term and the hypothetical behavioral processes (positive
reinforcement, negative reinforcement, intermittent reinforcement, punishment, and
extinction). For an in-depth look at the chain analysis protocol, see Rizvi and
Ritschel (2014) and Rizvi (2019).

Fig. 10.1 Graphic representation of chain analysis

138 J. L. Leonardi and D. Josua

After concluding the chain analysis, the therapist and the patient proceed to plan-
ning and implementing the intervention – phase called solution analysis. As
explained by Heard and Swales (2015), the first step consists of selecting elements
from the chain analysis that needs to be modified according to how strongly and
frequently they exert control over the behavior as well as how difficult it is to change
it. Next, therapist and client name as many forms as possible to interrupt the occur-
rence of problem behaviors and achieve their goals; at this point, feasibility, pros/
cons, and potential success of the solutions should not be considered. This second
step involves the therapist proposing specific intervention procedures for the
selected element of the chain, both those imported from behavior and cognitive-­
behavioral therapies as well as those developed by DBT itself. Implementing such
procedures must be done with guidance, in which the therapist (1) explains how it
works and how it can contribute to achieving a certain objective, (2) provides rele-
vant theoretical background, (3) specifies the course of action, and (4) describes
possible side effects.
That done, the therapist–patient dyad seeks to evaluate the effectiveness of the
proposed solutions by analyzing each one’s obstacles (repertoire deficit, other chain
elements, logistics), pros and cons, and possible outcomes. Whenever possible, cho-
sen solutions should be trained or tested in session, so that the patient is better pre-
pared to use it in other contexts. Finally, patients implement solutions in their daily
context and, after reported in session, therapists must evaluate the patient’s experi-
ence, give positive feedback, refine its implementation, and value the attempt –
regardless of its effectiveness. For a more in-depth analysis of solutions and various
interventions aimed at each chain element, see Heard and Swales (2015).
Such step-by-step description of the intervention can give the false impression of
simplicity or mechanism. Interventions with patients who present multiple diagno-
ses and substance abuse rarely take such a linear course. On the contrary, the dance
between the paradigms of acceptance and change are expected to occasionally occur
during chain and solution analyses.
In addition, before implementing solutions, the patient must be provenly moti-
vated to adhere to a certain therapeutic objective (e.g., lower cocaine use to zero),
abide by a specific procedure, or commit to the entire treatment plan (Koerner,
2012). As a recognition of the importance and difficulty to produce such motivation,
Linehan (1993) included commitment strategies drawn from the cognitive-­
behavioral tradition and social psychology research. Some consist of interventions
with curious names such as door in the face, foot in the door, and devil’s advocate.
An example consists of connecting current commitments with previous ones, in
which the therapist recalls a successful commitment episode in the patient’s life and
links it with the possibility of change in the current context. If a patient who is being
treated for cocaine says something like “Enough, I’m done with this! My life with-
out cocaine is unbearable! I’m doing some and that’s it!”, the therapist could reply
“It recently seemed impossible for you to go a single day without using, although
you’ve been rid of cocaine for the past three weeks now. Let’s rescue the moment
you made the decision to stop and what helped you to endure those times and try to
remake your commitment.”
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 139

Finally, in the dialectical paradigm, the therapist aims to balance the need for
acceptance and change to coexist both in the life and the treatment of patients with
chaotic lives. From a dialectical point of view, the therapist embraces the notion of
polarities and sees them as opportunities rather than obstacles to find syntheses in
the therapeutic process (Koerner, 2012). The dialectical posture allows flexibility
when facing common clashes in psychotherapy. Particularly relevant for DBT-SUD
is the idea of dialectical abstinence (explained in more detail below), which pro-
poses that abstinence and compassion for those who have returned are possible.
In addition, dialectics appears as a series of strategies on how the therapist can
handle the steadiness of the process and ensure movement. These strategies have
thought-provoking names and often try to convey the notion that tying with only one
side of the truth is unnecessary. In this sense, a strategy called entering the paradox
has remarkable effects, in which the patient is invited to experience the idea that
some dilemmas cannot be solved (Koerner, 2012). For example, the therapist genu-
inely cares for a patient and, at the same time, is paid to care (and, to some extent,
becomes less concerned once the payment ceases). Another interesting strategy is
the idea of ​​making lemons into lemonade, which proposes that some bitter situations
in life can be reversed into something as refreshing as possible. This is the case of a
patient who hates a colleague from skills training while also needs to exercise his or
her ability of not judging (mindfulness). The complete skills list can be found in
DBT textbooks (cf. Koerner, 2012; Linehan, 1993).

DBT-SUD-Specific Strategies

Although DBT-SUD is part of a therapeutic effort that falls within the scope of
standard DBT, some specific strategies have been developed to assist the population
that (also) suffers from substance use disorder. Like other DBT concepts, this skill
set can be remembered by its acronym DCBA – dialectical abstinence, clear mind
and community reinforcement, burning bridges and building bridges, alternate
rebellion, and adaptive denial.

Dialectical Abstinence

As Linehan (2015) explains, dialectical abstinence is a relapse prevention strategy

that integrates the goal of total abstinence whenever one is suffering from with-
drawal symptoms (even for a short time) and adequate damage control at each
relapse. Here, the patient is instructed and encouraged to (1) establish a solid com-
mitment to abstinence, (2) plan how to remain abstinent, and (3) manage relapses to
avoid getting worse. Some examples of absenteeism and relapse management
involve calling the therapist –or other people who can be of help—, writing down
the pros and cons of using the substance; eliminating rules like “I’ve already done
140 J. L. Leonardi and D. Josua

drugs today, so I’m not abstinent anymore and it doesn’t matter whether I do more
or not”; renew the commitment to total abstinence –telling themselves this was the
last time they relapsed; etc.

Clear Mind

Linehan adopted and adapted several techniques from his experience with Zen
Buddhism (Koerner, 2012; Swenson, 2016), among which stands the notion of three
states of mind, namely the rational, emotional, and wise mind. According to Linehan
(2015), DBT-based treatment fundamentally includes helping patients to get out of
severe oscillations between the emotional, excessively impulsive, and immediate
mind and the rational, excessively cold, and calculating mind. Thus, there would be
a third state of mind, inherent to any human being (and more than the mere intersec-
tion between emotional and rational mind) that would allow a response that is both
adapted to life situations and faithful to one’s values. Linehan calls this a wise mind
and argues that accessing this type of functioning is essential, as it favors good
decision-making by ensuring that such a process is both intuitive, immediate, and
aligned with important long-term values ​​(Linehan, 1993). For DBT-SUD and other
addictive behaviors, Linehan (2015) developed similar concepts, called addict
mind, clean mind, and clear mind.
The addict mind is a state in which the individual is dominated by addiction, so
that behaviors, thoughts, and emotions are focused on consuming the substance. In
this context, the individual exhibits behaviors such as glamorizing the drug, stealing
to finance their addiction, buying paraphernalia, and, of course, using the drug. In
addition, the addict mind involves thoughts such as “I am not a drug addict” or “no
problem if I do drugs only once a week,” as well as the urgency to eliminate craving
sensations, such as dysphoria, jittering, sweating, and body temperature changes. In
a nutshell, the addicted mind makes the patient willing to do anything for one dose.
Individuals with a clean mind present seemingly irrelevant behaviors that had
previously led to substance use (e.g., going out with the same friends, to the same
type of party where it occurred), in addition to keeping paraphernalia, lowering or
interrupting medication, and abandoning treatment. This state of mind also involves
thoughts such as “I am healed” and “I can solve my own problems,” associated with
a sense of control and invincibility. In short, patients with clean minds risk over-
looking the dangers of having a relapse when seeing themselves immune to the
temptation of consuming the substance.
The clear mind – intervention goal—is the synthesis of the dialectical tension
between addict and clean mind. In this state, individuals can and should enjoy the
success of their abstinence, but also accept the possibility of a relapse and thus make
plans for when feeling compelled to use the drug. In the words of Linehan (2015):
Overcoming addiction is like fighting a long war against urges to engage in the addictive
behavior. The urges win a battle when you end up doing the addictive behavior, and you win
when, despite the urges’ attacks on you, you don’t do the addictive behavior. Clean mind is
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 141

forgetting the war once a few battles are over, it’s thinking that because you’ve repelled the
urges a few times, they will not come back, or that if they do come back, they will be easy
to repel. When you are in clean mind, you don’t prepare for battle, and your defenses are
down. Urges can catch you unprepared and win. Addict mind is like being under siege by
the urges and believing that you can never repel them again. When you are in addict mind,
you don’t remember your victories; when you are defeated, you don’t regroup and fight
back. Clear mind is remembering both your victories and your defeats, fighting with all
your might, and staying prepared for battle even when you are experiencing no urges.
(Linehan, 2015 p. 483)

Community Reinforcement

Based on the concept of operant behavior (cf. Skinner, 1938/1991) –in which sub-
sequent events can retroact and alter the individual’s behavior in the future—com-
munity reinforcement (cf. Meyers & Smith, 1995) aims to strengthen behaviors that
are alternative and/or incompatible with drug use, such as spending time with non-
addicts, playing sports, trying new activities, going to the movies, listening to music,
reading, learning a new language, and structuring a career.
A central aspect of community reinforcement refers to behavioral experiments
on abstinence. Based on the premise that full abstinence can be difficult to achieve
and increase the chances of treatment dropout, the therapist encourages short absti-
nence periods. After the client having spent 2 days without using the drug, the thera-
pist has the role of valuing this achievement and encouraging gradually longer
periods. In parallel, the patient can engage in various pleasurable activities while
abstinent, which can only occur when not under the effect of the substance.

Burning Bridges and Building New Ones

As explained by Linehan (2015), burning bridges corresponds to all behaviors that

patients exhibit to eliminate any stimuli involved in substance consumption from
their lives. The goal is for the patient to get rid of phone numbers, e-mail addresses,
and other contact information of drug dealers or friends who contribute to drug use,
as well as clothing and household items associated with the substance and drug use
paraphernalia (syringe, herb grinder, lighter), among others. The point is to destroy
anything that makes addictive behaviors more likely.
In turn, building new bridges is the strategy of creating images and smells as
vividly as possible to compete with the stimuli involved in a craving episode.
Roughly speaking, the idea is to distract the patient from the sensations, images, and
smells related to addiction and thus lessen the urge to consume the substance.
142 J. L. Leonardi and D. Josua

Alternative Rebellion and Adaptive Denial

If addictive behavior is intended to express revolt, disobedience, or insubordination

to a person or society, other behaviors can be used as substitutes. Alternative rebel-
lion aims to meet the need patients have to rebel without affecting their life quality
by engaging in activities –as suggested by Linehan (2015)—such as shave the hair
off, dye the hair an extravagant color, make a tattoo, expose unpopular opinions,
give an honest rather than a polite answer, wear clothes inside out, wear shoes from
different pairs, print a social criticism message on a t-shirt, and post a world view
on a blog or Facebook feed.
Adaptive denial, on the other hand, can be understood as a “mental vacation” for
logical arguments concerning the risk of using the substance. By adopting this strat-
egy, patients force themselves to say they are not going to do the drug now – even
when the impulse is particularly high. In the words of Linehan (2015), “Adaptive
denial’ refers to adamantly convincing yourself that you don’t want to engage in the
addictive behavior when an urge hits, or that the addictive behavior is not a possibil-
ity.” (p. 490). Thus, patients are invited to engage in another task such as counting
coins in a glass jar while repeating to themselves “I need to count these 10-cent
coins.” Alternatively, they can simply commit to not using the drug for 5 min and
then extending this period for another minutes, and so on.

Patient Consultancy Vs. Environmental Intervention

In addition to DCBA skills, an important adaptation of DBT-SUD concerns the

relationship between patient consultancy versus environmental intervention.
Standard DBT emphasizes the need for the patient to independently produce impor-
tant consequences. Thus, direct interventions made by the therapist in the client’s
environment are an exception. Conversely, due to the frequency with which addicts
omit information on their substance use, DBT-SUD uses toxicological tests –such
as urine tests and breathalyzers—which are common in empirically supported treat-
ments for substance use. In other words, while standard DBT therapists emphasize
patient consultancy, DBT-SUD favors environmental intervention.

A Brief Clinical Example

The patient – Bia (fictitious name)—came to the clinic without a diagnosis but little
analysis was necessary to assess the severity of the case. Both shallow (more recent)
and deeper (slightly older) scars on her arms pointlessly tried to hide behind skull
tattoos. The blunt speech hid a den of anger and resentment towards her parents who
“could never understand her”.
10 Dialectical Behavioral Therapy (DBT) for Substance Use Associated… 143

Since she was little, she felt different, more sensitive than other people. Even
before she turned 10, she experienced violent anxiety episodes before going to
sleep. The parents, facing their daughter’s increased sensitivity, simply told her to
stop with the nonsense and go to sleep. Her talking about her childhood seemed
almost like a literal description of Linehan’s (1993) biosocial model.
During her adolescence and early adulthood, her emotional dysregulation crises
worsened, and she began a cycle of self-harm combined with alcohol abuse. The
relief brought by alcohol intake and self-injuries in her arms gradually demanded
larger doses and deeper perforations. By the age of 25, alcohol use had already
extended to cocaine followed by crack –self-harm, although without a suicidal
intent, had already taken her to the hospital twice.
It took just over a month of work (and psychiatric care assistance) for target
behaviors to be established in collaboration with the therapist – zeroing the use of
crack, cocaine, and self-harm, as well as not consuming alcohol for at least 6 months.
As the use of crack was uncontrolled and put her physical integrity at risk (spending
days “lost” in the city’s biggest community of crack addicts called Cracolândia),
this was ranked as the highest behavior in the hierarchy, followed by self-harm, and
then by cocaine and alcohol. The latter was important mainly for constituting a
frequent link preceding her crack relapses, as revealed by chain analyses.
However, at the beginning of treatment Stage 1, Bia realized the size of her chal-
lenge, especially in abandoning substance dependence. She asked to be admitted to
a rehabilitation clinic to earn (in her words) “a breather.” At that moment, it was
essential to validate her sense of helplessness – as she really seemed to lack the tools
to solve the problem—and the desperation to find herself trapped in a self-­
destructive cycle.
During rehab, it was essential to take advantage of her free time to ensure that
she continued with her skills training. Interestingly, a series of chain analyzes
showed that cocaine use was particularly associated with the presence of a specific
friend. When talking about the ability to “burn bridges to build new ones,” Bia
promptly offered to completely suspend contact with this friend at least during the
first year.
However, several other concepts were still challenging. She found it especially
difficult to tolerate mindfulness exercises, since it seemed unbearable to endure the
bodily sensations linked to the process of doing less busy activities –such as observ-
ing her own breathing. The notion of clear mind or dialectical abstinence, on the
other hand, seemed particularly difficult to achieve in the rehabilitation environ-
ment. Within the security of hospital gates, the idea of relapsing into drug use
seemed exceptionally distant.
Thus, not surprisingly, the first post-hospitalization session was marked by a
relapse. After being contacted by the psychiatrist to arrange the first urine test –
scheduled as a routine – Bia performed a quick mental calculation and realized she
only had that day to do crack without getting caught by the test. In this session’s
chain analysis, the doctor’s message was understood as the triggering event, while
all the movement between the mental calculation and crack use (about an hour later)
were marked as links. The target behavior (or problem) was the drug use itself. The
144 J. L. Leonardi and D. Josua

reinforcing consequences are linked to all the chemical effects of the drug in her
body. However, we must also highlight delayed (aversive) consequences –in par-
ticular, the remorse, feeling of incompetence, and boyfriend’s disapproval (with
whom she lived).
In this context, it is essential to establish a list of solutions to prevent this chain
of events from reoccurring by first scheduling test intervals without this window of
opportunity for use. Then, enabling her to talk to the psychiatrist so that these inter-
vals could be adjusted (in this scenario, interpersonal effectiveness skills, with
emphasis on patient consultancy, were particularly important). Other solutions –
DBT skills that Bia had trained during hospitalization – were discussed, such as the
importance of knowing how to get distracted and waiting for emotions to fade,
known in DBT as the ACCEPTS skills and emotional mindfulness.
Treating patients like Bia – with multiple diagnoses and a lifelong suffering – is
certainly never simple or linear. Nevertheless, it is essential to note how DBT-SUD
can help to structure the treatment to prevent the therapist from sinking into the cli-
ent’s ocean of difficulties. If, on the one hand, the ups and downs are expected, on
the other, it is essential to always be prepared to deal with inevitable relapses and,
above all, restructure both the treatment and the motivation of the patient (and thera-
pist) involved in this type of psychopathology.

Final Considerations

This chapter described the adaptation of DBT by Linehan and collaborators for the
comorbidity of substance use and borderline personality disorder (titled DBT-SUD).
We briefly presented the central principles of DBT and detail the elements that con-
stitute DBT-SUD, both from the perspective of theory (biosocial model) and clinical
practice (treatment stages, intervention techniques, and specific strategies for addic-
tive behaviors).
Finally, we must note that, although DBT-SUD may be effective for substance
use disorder without the presence of BPD, it may not be advantageous when com-
pared to other substance use interventions with empirical support that tend to be
more direct and require fewer implementation resources. In addition, the focus on
chronic emotional dysregulation as the underlying process that drives substance use
in DBT-SUD may not be widely applicable to individuals who only suffer from
SUD. On the other hand, DBT-SUD could be justified for individuals with SUD and
other comorbidities marked by emotional dysregulation.

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Chapter 11
Contributions of Acceptance
and Commitment Therapy (ACT)
with an Emphasis on Values
and Committed Actions in the Treatment
of Substance Dependence

Rafael R. de Q. Balbi Neto and Simone Martin Oliani

Introduction

Acceptance and Commitment Therapy, with the abbreviation ACT, is a therapeutic

approach currently recognized as empirically grounded for the treatment of some
mental disorders, according to the Society of Clinical Psychology – also known as
Division 12 of the American Psychological Association (APA). The main disorders
treated with ACT are Depression, Mixed Anxiety Disorders, Obsessive-Compulsive
Disorder, Psychotic Disorders, and it is recognized for the treatment of Chronic
Pain (APA, 2016). On the topic of Substance Use Disorder (SUD), there are empiri-
cally based treatments for the use of alcohol, cocaine, and tobacco, the Contingency
Management (as described in Chap. 7 of this book), also proposed by APA (2016),
being among them.
ACT is relevant in the treatment of substance dependence for two reasons: (a)
anxiety and depression comorbidities are frequent; and (b) ACT can enhance the
effects of other treatments, such as Contingency Management. Comorbidity rates in
SUD and mood disorders are very high, reaching 20.13%, with Major Depressive
Disorder being the most frequent, present in approximately 15% of patients diag-
nosed with SUD. Anxiety disorders are close to 18% of all the people diagnosed
with SUD, with Specific Phobia being the most frequent disorder, present in about
11% of cases (Grant et al., 2006). In addition, recent studies developed in Brazil
(e.g., Silveira et al., 2018; Silva et al., 2018) point out that Mental Disorders are
more prevalent in users of psychoactive substances (PAS) than in the general

R. R. d. Q. Balbi Neto ()

Universidade Federal do Espírito Santo, Vitória, ES, Brazil
S. M. Oliani
Centro Integrado de Neuropsiquiatria e Psicologia Comportamental (CINP), Londrina, PR,
Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 147
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_11
148 R. R. d. Q. Balbi Neto and S. M. Oliani

population, and that patients with Depression or Schizophrenia are more likely to
develop SUD.
Although there is a lack of research that recognizes ACT as an empirically based
treatment for SUD, A-Tjak, Davis, Morina, Powers, Smits, and Emmelkamp (2015),
in a review, concluded that “ACT is more effective than treatment as usual or pla-
cebo and that ACT may be as effective in treating anxiety disorders, depression,
addiction, and somatic health problems as established psychological interventions”
(p. 30). Furthermore, according to Stotts and Northrup (2015), studies on ACT and
DBT (Dialectical Behavior Therapy, presented in Chap. 10 of this book), carried out
in different populations, have shown that these types of interventions are promising
for the treatment of SUD regarding the use of various substances such as: opiates,
methamphetamine, multiple substances and within varied environments, namely:
prisons, methadone clinics, residential, and outpatient treatment.
A reference article was published by Hayes, Wilson, Gifford, Bissett, Piasecki,
and Batten (2004). They compared the treatment as methadone-only use with the
treatment of methadone combination with 16 weeks of Twelve Step Facilitation
Therapy (TSF) or Acceptance and Commitment Therapy (ACT) in an efficacy study
with opiate addicts who abuse substances and who continued to use PAS while on
methadone treatment. The results showed that treatment with ACT led to a reduced
drug use. Hayes et al. suggested that both ACT and TSF should be focused on fur-
ther studies to assess effectiveness as a resource that makes it possible to reduce the
harmful use of psychoactive substances (PAS).
Subsequent studies (e.g., Stotts et al., 2009, 2012) have shown positive results in
the treatment of opiate addiction with ACT and DBT. Another example is the study
by Luoma et al. (2008), in which ACT was used in a 6-hour workshop to reduce
self-stigma in 88 patients with SUD. The results showed medium to large effects on
many variables in the post-treatment, signaling the relevance of ACT as a comple-
mentary treatment for SUD, which in turn may reduce the risk of relapse.
ACT can also enhance the effects of other treatments, such as Motivational
Interviewing and Relapse Prevention Therapy, as proposed in the work Mindfulness-­
based sobriety: a clinician’s treatment guide for addiction recovery using relapse
prevention therapy, acceptance and commitment therapy, and motivational inter-
viewing (Turner et al., 2014) and Mindfulness-based relapse prevention for addic-
tive behaviors: A clinician’s guide (Bowen et al., 2011). Likewise, ACT therapeutic
processes, such as Mindfulness, can collaborate with the treatment of SUD, which
can be observed in different studies (e.g., Witkiewitz et al., 2013; Wupperman et al.,
2015) regarding substance dependence.
In this chapter, a description of ACT based on the principles of Behavior Analysis
will be presented, explaining briefly its processes. Afterward, some aspects of ACT
that may contribute to the treatment of substance use disorder will be specified.
Finally, a description of two techniques related to the therapeutic process of
Committed Actions will be presented, which demonstrate the relationship of four
processes, Mindfulness, Acceptance, Disclosure, and Contextual Self, the applica-
bility to Values and
​​ Committed Actions with a valuable life and without drug abuse.
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 149

Principles of Behavior Analysis in Explaining ACT

The first book that presents ACT in a systematic way is “Acceptance and Commitment
Therapy: An experimental approach to behavior change” (Hayes et al., 1999). When
read by behavior analysts in Brazil, it raised doubts as to whether ACT would be
based on Behavior Analysis. This doubt may have been minimized with the publica-
tion of the article “Acceptance and Commitment Therapy: Is it a Cognitive
Intervention Proposal?” (Costa, 2012). Costa (p. 117) stated that ACT is a “thera-
peutic model completely compatible with Skinner’s Radical Behaviorism and
Behavior Analysis”. In 2014, ABPMC (Brazilian Association of Psychology and
Behavioral Medicine) recognized the book “Acceptance and commitment therapy:
An experimental approach to behavior change” (Hayes et al., 1999) as a source of
guidance for the analyst’s work and considered valid by ABPMC (2014), as well as
publications on Relational Frames Theory (RFT), which supports a large part of the
interventions in ACT. Given the documents, it is suggested that ACT is a proposal
primarily based on Behavior Analysis.

ACT Processes

ACT proposes six therapeutic processes, called Acceptance, Cognitive Defusion,

Mindfulness, Dimensions of the Self, Values, ​​and Committed Actions. Each of
these therapeutic processes develops different skills in clients so that the result is an
increase in Psychological Flexibility. The term Psychological Flexibility is related
to the ability to experience difficult thoughts and emotions, being able to perceive
oneself within this process and still walk in the direction of what really matters to
build in life, connected with one’s values, guiding one’s actions to live a meaningful
life. This term proved to be of little use in practice, as apparently, it is of little to no
interest for clients to know if they are developing “Psychological Flexibility”. On
the other hand, the term can be useful from a theoretical point of view, for example,
in researches such as that of Kashdan and Rottenberg (2010), which correlates
Health with Psychological Flexibility.
ACT is a very different proposal from anything that clients have ever known in
western culture, so it is important to prepare them for the processes of ACT (espe-
cially Acceptance and Disclosure). The therapist must assist the client in assuming
that in order to learn something new it is necessary to put aside what has been done
to deal with negative thoughts and feelings so far, at least, for a while. This prepara-
tion in ACT is called Creative Helplessness (or Creative Despair), and it can be done
in several ways, like the Creative Desperation Exercise (Saban, 2015) or the Man in
the Hole metaphor (translated by Saban 2011).
To understand Acceptance and Defusion, it is important to understand the con-
cept of “experiential avoidance” of ACT. We take the following point of view,
invariably, human beings are faced with events and/or stimuli during life, which can
150 R. R. d. Q. Balbi Neto and S. M. Oliani

produce “negative feelings” and “negative thoughts”, such as aversive contexts of

different types. “Negative feelings” can be identified as being the feelings consid-
ered as having aversive characteristics to Western culture, like sadness, fear, anger,
disgust, frustration and its variations, such as anxiety, disappointment, guilt, dis-
trust, despair, irritation, annoyance, loneliness, and shame. “Negative thoughts” are
covert verbal behaviors that produce negative feelings through different types of
relational processes (literalness, assessment, reason-giving), as proposed by Hayes
et al., 2011), as “something of bad will happen” (literalness, treating thoughts as if
they were facts), “I am a failure” (assessment, treating evaluations as descriptions),
“I use drugs, because I feel cracked and addicted” (reason-giving, feelings, and
labels that cause/justify actions).
Cognitive fusion is defined as one of three relational processes: literalness,
assessment, and reason-giving. In turn, from an analytical-behavioral point of view,
it can be said that clients with SUD generally say they use a certain substance to
evade or to escape from negative internal experiences (feelings or thoughts), that is,
they report avoidance of verbal or emotional covert behaviors, which is character-
ized as being a negatively reinforced behavior.
Substance use often momentarily relieves the “emotional pain” described by cli-
ents, but reinforces the covert operant behavior and the aversive emotional or verbal
response. The operant behavior returns strengthened for a short period, with greater
frequency and/or magnitude of response, as it was negatively reinforced with the
end of aversive stimulation. And in general, it is again “controlled” by users with a
more intense substance use, which strengthens or develops addiction. ACT
Acceptance processes train skills in clients to better deal with negative feelings aris-
ing from life facts which have no solution or that there is nothing more to be done.
Defusion processes help the client to develop skills to better deal with negative
thoughts, which are not functional.
Mindfulness processes seek to help clients stay more connected to the present, in
the here and now, in a more flexible way. The term mindfulness is difficult to trans-
late, even more to find a technical word that defines it. In Behavior Analysis, the
proposal is to analyze functionally and not be under control of the topography and,
to facilitate, we will then describe the behavioral processes that are present in this
proposal. It is being present in the present moment. Discriminating both internal
and external stimuli. Observing thoughts without judgment or avoidance. Accepting
feelings and its respondents as such (Tsai et al., 2009).
The skills developed with mindfulness practices work as support for the other
therapeutic processes, since all processes occur in the here-now. Being mindful – in
touch with the here-now – is very advantageous for clients who spend a lot of time
thinking about the future, popularly called “suffering by anticipation” or the past
that cannot be changed in the present. In ACT, the past is considered to be gone
forever, the future has not yet happened, and behaviors regarding the past and future
occur in the present. As a result, concerns about the future and anxieties about the
past have much less effect on clients. Substance users report difficulty sleeping due
to “accelerated thinking”, in general, mindfulness practices help to “slow thoughts
down”, which makes sleeping easier. As a therapist, some care must be taken to
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 151

train mindfulness after doing Creative Helplessness, as clients can use mindfulness
practices with the same function as using substances, that is, to evade aversive
covert experiences.
The Dimensions of Self processes develop abilities to see oneself from various
perspectives, favoring the development of seeing the world in a more flexible way.
As in Radical Behaviorism, in ACT it is understood that clients can assume three
dimensions about themselves: The conceptual I (conceptual self), procedural I (pro-
cedural self), and contextual I (contextual self). The conceptual self is developed
based on the properties of the overt responses that clients emit in a verbal commu-
nity, that is, it is the result of the process of forming the concept of the self (“me”).
The conceptual self process produces labels and adjectives about itself, such as
“calm”, “aggressive”, “peaceful”, and “tough”. The processes of the conceptual I
are excessively reinforced in Western culture, in such a way that it seems to be the
only possibility of concept of the self. The conceptual self perspective is not a prob-
lem in itself, but the inflexibility in this dimension.
The procedural self is the “self” that emits operant or respondent responses, in
the here-now. Being mindful becomes very relevant to notice the procedural self. As
clients train this new perspective of themselves, they begin to notice that they are
more than the labels they receive from themselves and others, and that they are also
the repertoire they show in the present moment. Behavioral therapies in the second
generation already proposed, directly or indirectly, the training of the procedural
self, which makes the dimensions of the self more flexible (Wolpe, 1978; Sampaio
& Roncati, 2012).
The contextual self is a much more refined perspective of oneself, as it consists
of noticing that there is a contextual “self” for the occurrence of concepts and pro-
cesses. This proposal appears only in third-generation behavioral therapies. The
conceptual and procedural self are contained within the contextual self, since the
formation of the concept of the self and the emission/elicitation of responses take
place in a certain context. When trained in the contextual perspective, clients begin
to “perceive that they perceive”, to “notice that they notice”. Noticing is a process
that takes place in an “I” context, where one can notice that one is noticing. Working
with the dimensions of the self with clients results in a higher flexibility, as a reper-
toire addition in the development of perception skills regarding the perspective of
oneself. Like Mindfulness processes, the Dimensions of the Self support other ther-
apeutic processes.
Values in ACT are defined as “consequences verbally constructed from continu-
ous, dynamic and evolving activities, which establish predominant reinforcements
for these activities that are intrinsic to the engagement in the valued behavioral pat-
tern itself” (Wilson & DuFrene, 2009, p. 66). To complement this definition, it can
be said that values in ​​ ACT are arbitrarily reinforced sets of verbal abstractions of
positive reinforcing response classes, that is, verbal abstractions that have been arbi-
trarily reinforced within a verbal community, which constitute values when together.
In other words, values are ​​ sets of qualities of actions, whether broad or specific. The
greater the amount of abstractions in a value, the broader the value becomes, such
as the values ​​“family” or “work”. On the other hand, values ​​consisting of few
152 R. R. d. Q. Balbi Neto and S. M. Oliani

abstractions are more specific, such as “intimacy”, which can be contained in broad
values ​​such as “family” and/or “work”, given its specificity.
It is important to highlight that, in the therapeutic process, the client will clarify
the values that
​​ he or she already has, which were acquired throughout one’s history
of reinforcement in life. There is no way to teach the client values in a therapeutic
process, since this is absolutely contingent, that is, the client learns about values, not
about having or not having values, in the therapeutic process.
The process of Committed Actions begins after working on some process of
clarifying Values. Clients will not be able to choose Committed Actions if they
aren’t clear enough about their own values. Committed Actions are operant
responses related to the clients’ values, that is, abstractions, which define Values,
also present in Committed Actions. By definition, Committed Actions do not func-
tion as Experiential Avoidance, so behavioral responses with an escape function are
not Committed Actions functionally. They are also characterized by producing posi-
tive feelings in clients, such as: satisfaction, joy, pride, tranquility, hope, even in the
face of high response costs, which includes facing aversive stimuli. The positive
feelings produced by Committed Actions are indicative of the occurrence of posi-
tive reinforcement. For example, for a client with the value of “paternity”, even if
unmotivated, “playing with the child” is a Committed action, when the result is the
production of satisfaction (positive feeling).
Negative feelings can be produced by the lack of Committed Actions, in general,
by a state of deprivation, which increases the value of reinforcement. In this case,
Committed Actions do not have an escape function, and are, in fact, the only way to
eliminate the negative feeling (covert aversive stimulus).
Notice that negative feelings can come from three factors: (1) events in clients’
lives with no possibility of control; (2) negative thoughts with the function of
Cognitive Fusion (literalness, evaluation, and reason-giving); and (3) behavioral
deficit (lack of Committed Actions). Acceptance deals with factor 1, Defusion with
2, and Values ​​combined with Committed Actions with 3. Realize that behavioral
excesses are produced with the function of Experiential Avoidance, responses with
the function of escaping feelings and negative thoughts. For example, when a client
uses substances to eliminate negative feelings or thoughts.
ACT processes are grouped in pairs, Acceptance and Defusion are processes of
opening, Mindfulness and the Dimensions of the Self are processes of centering,
Values ​​and Committed Actions are processes of engagement. Clients diagnosed
with mood disorders, anxiety, and obsessive-compulsive disorder, usually have
more difficulty opening up, that is, a great deal of difficulty to deal with negative
thoughts and/or feelings, suggesting processes of opening as the beginning of treat-
ment (Acceptance and Defusion), going through processes of centering and after-
ward of engagement. On the other hand, clients with impulse, eating and substance
use disorders have more problems related to impulsivity and compulsiveness than
problems related to the opening processes, that is, dealing with negative thinking
and feeling, which suggests the beginning of treatment by engagement processes
(Values ​​and Committed Actions).
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 153

With the client’s engagement in the therapeutic process and having worked on
Acceptance, Defusion, Being Present and the Dimensions of the Self, the therapist
will work on clarifying the client’s values ​​(processes of Values), it becomes appro-
priate to apply techniques to identify and organize Committed Actions. Below is the
description of two very useful strategies, the Action Scanner and the ACT Matrix.

ACT Practical Applications with Committed Actions

Some books are reading suggestions to deepen the theoretical and applied knowl-
edge of ACT, such as “Introduction to acceptance and commitment therapy” (Saban,
2011) in which there is a translation of ACT intervention metaphors and techniques
proposed by Hayes et al. (1999), which won a second edition in 2011 (Hayes et al.,
2011) and without forgetting the material called “Working on Values -​​ For a Life
with More Meaning and Purpose” (Voguel, 2019).

Action Scanner

After some therapeutic process with Values, it becomes interesting to apply the
Action Scanner, especially after filling out instruments, such as the Values Narrative
Form and Valued Living Questionnaire-2, as explained by Hayes et al. (2011), or
another instrument with a list of values.
The Action Scanner (Appendix 1) has three columns. At the top of the first col-
umn is the title “Start…”, at the top of the second “Stop…”, and the third
“Continue…”. The second column is divided in half, creating an untitled space
underneath, a neutral space that serves to make observations or to be filled with
information that did not fit in the other columns (including the second one).
Ask clients to write observable actions in the three columns as a basis for each of
the values ​​he or she attaches some importance to. Although clients can start with
any of the three columns, in general, it is more interesting to start with the first one,
as they will write about reinforcing actions that are in deficit. Customers with SUD
have more difficulty identifying behavioral deficits, in this sense, helping them deal-
ing with it becomes more interesting and reinforcing for them than dealing with
excesses, such as the use of PAS.
The values ​​that guide the completion of the Action Scanner are present in the
instruments that clients have already filled in, such as Values ​​Narrative Form, Valued
Life Questionnaire-2, or another instrument, such as Family, Marriage/Intimate
Relationship, Maternity/Paternity, Friendship/Life Social, Work, Education/
Training, Recreation/Fun, Spirituality, Community Life, and Body Self Care. They
can follow the order of the values ​​on the instrument or choose the order itself. In the
case of choosing the order itself, it is interesting to write it down on the instrument
(Values ​​Narrative Form and/or Valued Life Questionnaire-2), as they fill out the
154 R. R. d. Q. Balbi Neto and S. M. Oliani

Action Scanner, in order not to get lost in filling it out. Notice that clients need to
describe the action in a way they do not depend on another instrument to understand
it. For example, the client starts describing actions related to marriage and writes
“being affectionate”, the therapist may ask “being affectionate to everyone or only
in marriage?” If the client’s response is “with everyone”, the description of the
action “being affectionate” is correct; on the other hand, if the client’s response is
“only in marriage”, the description of the action “being affectionate” needs to be
more specific, being changed to “being affectionate in marriage” or “with the wife”.
Notice that it makes no sense to write actions of values that​​ clients do not care
about, that is, values ​​that are meaningless to them, even if they have value for soci-
ety, such as spirituality and/or maternity/paternity. In addition, it is important to
help identify preferentially observable actions – overt behavior, since the covert
behaviors will be handled, in large part, through Acceptance and Disclosure pro-
cesses. A strategy to help clients stay focused on observable behavior is to ask them
to write it down on the instrument behaviors that can be filmed (Polk et al., 2016).
In the third column, “Continue ...”, there are many actions, as clients perform
many actions they wish to maintain. In order to increase the efficiency of the inter-
vention, ask clients to write preferentially observable actions that they have been
trying to do lately, which is the ones where there is a response cost. Actions that are
already on “autopilot”, called unconscious operants, which require little or no effort,
that is, with low response costs, do not need to be included in the “Continue…” list.
It is advantageous to write in the three columns everything that clients consider
important for a “life change”, such as a brainstorm, without judgment, regardless of
the priority or viability of the actions. There is no limit to the number of actions to
be written, offer a second sheet, if applicable, even though most clients use only 1
sheet. The Action Scanner makes it clear what needs to be done by the client, and
the instrument organizes the action planning in a more concrete way, according to
the clients’ own report. In addition, it serves as a preparation for the application of
the Likegram.

Likegram

The classical Likegram (Andrade, 1999) consists of four areas in which clients
write down actions. The areas have the following headings “I like and do it”, “I
don’t like and do it”, “I like and don’t do it”, and “I don’t like and don’t do it”. The
variable “like”/“don’t like” refers to the production of positive (in the “like”) or
negative/absent (“don’t like”) emotions, and the variable “I do”/“I don’t” refers to
the occurrence of the action or not, lately, in the client’s life. The Likegram in this
format can create more problems than solutions for clients and therapists: (1) it
allows the entry of reinforcing actions (“like”) in different categories at the same
time, such as “drug use” in “like and do” and “don’t like and do”, which produces
more conflict for the client; (2) the client may reach the conclusion that he or she
needs to do what he or she “likes” regardless of the delayed aversive consequences,
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 155

since it is the only variable of analysis to emit the behavior or not, such as “eating
too much sweet/salt/fat”, “being aggressive” or “using drugs”, and (3) the category
“don’t like and don’t do” can be filled with a multitude of actions without any thera-
peutic objective, which greatly reduces the efficiency of the therapeutic process.
In view of the previous Likegram limitations and problems, the ACT Likegram
(which could also be called Likegram of Committed Actions) was created, which
introduces another variable, “It is Important”/“It is not Important” based on the
ACT Values proposal.
​​ As a result, the ACT Likegram (Appendix 2) has six areas for
listing actions: (1) “like and do it because it is important”, (2) “I want to, but I don’t
do it (or avoid it), because it isn’t important”, (3) “I don’t like it but I do it, because
it is important”, (4) “I like it but I don’t do it, even if it’s important”, (5) “I do it
because I like it (or relieves me), but I shouldn’t do it, because it is not important”,
and (6) “I don’t like it and I don’t do it, but I should do it, because it is important”.
Notice that category 2 “like” is represented by “I want”, an easier way for the cate-
gory to be understood by clients, also called the “avoided temptations” category. In
the way the categories of the ACT Likegram were described, it is understood that
the arbitrarily applied relational response emerges, that the client needs to prioritize
what is “important” over what he or she “likes” and “is not important”, as pro-
posed by ACT.
Notice that the action the client “doesn’t like” and “is not important” does not
exist, they are literally dysfunctional or maladaptive behaviors. If at any time they
exist, it makes no sense to talk about them anymore, as they no longer have reinforc-
ing properties. The ACT Likegram has six categories and not eight. It is recom-
mended to apply the Action Scanner before applying the ACT Likegram, even with
asymptomatic clients and with good self-knowledge, such as psychologists.
Ask clients to classify the actions listed on the Action Scanner on the ACT
Likegram, which is not about filling in one category followed by the other, but
rather framing the actions already listed in one of the six categories, with which
some categories may remain blank.
Take advantage of this moment of transcribing the Action Scanner to the ACT
Likegram to refine the description of the actions, when applicable. “Generic
actions”, which describe many actions, can be subdivided to improve the descrip-
tion, such as “taking care of health” can be subdivided into “doing therapy”, “using
medication correctly”, “following the diet”, “doing physical exercise” and “Do rou-
tine exams” . In addition, instruct clients to write actions in the affirmative, for
example, instead of “not being aggressive” (or “Stop being aggressive”), writing
“be kind and affectionate”.
Some clients write many actions on the Action Scanner, either using 2 sheets, or
compressing the writing on the edges of the sheet. In some rarer cases, they use 2
sheets, as they write in very large letters. With that, in both cases, an alternative
2-sheet format is recommended for the ACT Likegram (Appendix 3), providing
extra space for clients to write. If you start with the 1-sheet format, it is very difficult
to insert a second sheet, that is, when in doubt it is advised to use the alternative
2-sheet format in Appendix 3.
156 R. R. d. Q. Balbi Neto and S. M. Oliani

One of the therapist’s tasks is to help the client notice that he or she perform
actions that he or she “likes” (or relieves) and that are not important, that is, there
are short-term reinforcing behaviors that produce delayed aversive stimuli, such as
“using drugs” or “be aggressive”. In general, it is difficult for clients to assume that
they perform actions that “they don’t like and are important” or that they “enjoy (or
relieve) and are not important”. Remember that it is always possible to use the
instruments previously applied (Narrative Form of Values and/or ​​ Valued Life
Questionnaire-2) whenever the doubt arises whether a particular action is important
to the client or not.

Final Considerations

ACT becomes relevant in the treatment of substance-dependent clients for two rea-
sons: (1) anxiety and depression comorbidities are frequent; and (2) ACT can
enhance the effects of other treatments for SUD, such as Contingency Management.
Research with ACT and SUD has shown promise as an effective intervention for
substance-dependent clients, as it favors dealing with their experiential avoidance
when seeking to avoid suffering and the search for immediate pleasure with the
consumption of PAS, especially with the process of Acceptance and Defusion. The
processes of Mindfulness, the Dimensions of the Self, Values, and Committed
Actions help to engage the therapeutic program and build a hierarchy of values and
actions with a more meaningful life for the client.
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 157

Appendices

Appendix 1 – Action Scanner

Action Scanner

Start... Stop... Continue...

158 R. R. d. Q. Balbi Neto and S. M. Oliani

Appendix 2 – ACT Likegram

ACT Likegram

I LIKE AND I DO IT, I WANT BUT I DON’T DO I LIKE AND I DO IT

BECAUSE IT’S IT (or AVOID IT) BECAUSE BECAUSE IT’S
IMPORTANT J IT’S NOT IMPORTANT J IMPORTANT J

I LIKE AND I DON’T DO IT, I DO IT, BECAUSE I LIKE I DON’T LIKE IT AND I
EVEN BEING IMPORTANT IT (OR RELIEVES ME) DON’T DO IT, BUT I
L BUT I SHOULDN’T DO IT SHOULD DO IT BECAUSE
L IT’S IMPORTANT L
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 159

Appendix 3 – ACT Likegram

ACT Likegram J

I LIKE AND I DO IT, I WANT TO BUT I DON’T I DON’T LIKE IT AND I DO

BECAUSE IT’S IMPORTANT DO IT (or AVOID IT), IT, BECAUSE IT’S
J BECAUSE IT’S NOT IMPORTANT J
IMPORTANT J
160 R. R. d. Q. Balbi Neto and S. M. Oliani

Appendix 3 – ACT Likegram – Part 2

ACT Likegram

I LIKE IT AND I DON’T DO I DO IT, BECAUSE I LIKE I DON’T LIKE IT AND I

IT, EVEN BEING IT (OR RELIEVES ME) DON’T DO IT, BUT I
IMPORTANT L BUT I SHOULDN’T DO IT, SHOULD BECAUSE IT’S
BECAUSE IT’S NOT IMPORTANT L
IMPORTANT L
11 Contributions of Acceptance and Commitment Therapy (ACT) with an Emphasis… 161

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org/10.1002/jclp.22213
Chapter 12
Therapy by Contingencies
of Reinforcement (TCR) and Substance
Dependence: A Clinical Case Presentation

Alan Souza Aranha, Luciana Pellizzaro Naine,

and Claudia Kami Bastos Oshiro

Introduction

Therapy by Contingencies of Reinforcement (TCR) is a psychotherapy system-

atized, developed, and implanted by Guilhardi in 2004,1 but its development began
in the 1970s with the opening of the first behavioral therapy clinic in Brazil
(Guilhardi, 2003; Leonardi, 2015). TCR is fully committed to Behavioral Science
(BS): the philosophy of Radical Behaviorism (RB) (Skinner, 1945), the research
methodology (Andery, 2010), the concepts (Catania, 1998/1999) of Experimental
Behavioral Analysis (EBA), and Applied Behavioral Analysis (ABA) (Journal of
the Experimental Analysis of Behavior, available at https://onlinelibrary.wiley.com/
journal/19383711 and Journal of Applied Behavior Analysis, available at https://
onlinelibrary.wiley.com/journal/19383703), and procedures of behavior modifica-
tion technologically described with the possibility of replication (Baer et al., 1968)
and based on experimental evidence demonstrated by BS. The foundation of TCR
is that the psychotherapist is interested in all the client’s manifestations – thoughts,
emotions, behaviors, delusions, dreams, etc. – but in order to deal with these phe-
nomena, he identifies and alters the contingencies of reinforcement (CR) of which
such phenomena are a function. Thus, “TCR” is a descriptive name of the psycho-
therapist’s work (Guilhardi, 2004). Substance abuse, substance dependence (APA,
1994), and substance use disorders (APA, 2013) are labels that refer to a behavior
pattern of the individual who self-minister PAS regardless of the harm that

1
See also Martin and Pear (2009).

A. S. Aranha () · C. K. B. Oshiro

University of São Paulo, São Paulo, SP, Brazil
L. P. Naine
Institute of Therapy by Contingencies of Reinforcement, Campinas, SP, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 163
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_12
164 A. S. Aranha et al.

consumption causes. Diagnostic manuals (APA, 2013) are proposed to describe

phenotypes2 (“craving or strong desire or need to use drugs”) and molecular contin-
gencies (“the daily activities of the individual revolve around the substance”) that
facilitate communication among mental health professionals, but do not allow the
identification of the maintaining variables, nor the fundamentals of the evaluation
and intervention of a particular client. The TCR proposes to use the laws of BS and
knowledge about the effects of PAS to conceptualize and treat individualized cases
involving drug consumption. The goal of this chapter is to present the psychothera-
peutic model of TCR, the reasoning of TCR when applied to drug abuse cases, and
to exemplify with a clinical case.

 sychotherapeutic Model of Therapy by Contingencies

P
of Reinforcement (TCR)

The psychotherapeutic model of TCR can be illustrated when the client seeks help.
The client’s behavioral repertoire – the set of possible actions in all the contexts in
which he lives – is selected in his genetic and environmental history. The repertory
that has been built up over time comes into contact with the CRs and, if insufficient,
leads to a scarcity of positive reinforcers and/or generates aversive stimulation. The
products of the contingencies are felt by the client as suffering, although in general,
he is not aware of why he suffers and attributes his pains to spurious causes. When
unable to alter the pain on his own, the available escape behavior is to seek the help
of a psychotherapist who, theoretically, is trained for such activity. Client and psy-
chotherapist work together to analyze and modify the problem in which the former
finds himself (Guilhardi, 2004; Skinner, 1953).
The contingencies of reinforcement therapist respond to three variables in his
clinical work: his genetic and environmental history as a person, his theoretical and
practical training as a professional, and to the behaviors, verbal and non-verbal,
inside and outside the session, of the client and the people involved in the case
(Guilhardi, 2004). These sources of information allow the psychotherapist to inves-
tigate and identify, on the one hand, the deficits and excesses (Kanfer & Saslow,
1976) that prevent the client from producing positive reinforcement and/or eliminat-
ing short- and long-term aversive stimuli for himself and ideally for others (Ferster,

2
The TCR adopts the term phenotype to illustrate that a response can have the same appearance
(phenotype) but different functions. For example, the running response may have, for one person,
the function of escape, while for another person the function of chasing. In this example, responses
with the same phenotype are different behaviors. On the other hand, responses with different phe-
notypes may have the same function. For example, crying and swearing are responses with differ-
ent phenotypes that can have the function of avoiding or escaping punishment. The word
topography comes from the Latin topic, meaning place. The term “topography” has been used to
refer to where the response was emitted and not the form of the response. There is a topography for
bar pressure (a single place, the bar on the wall), but several pressure phenotypes (pressing with
one or two legs).
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 165

1972) and, on the other hand, the CRs of which the deficits and excesses are a
function.
TCR begins the psychotherapeutic process by identifying several classes of dif-
ficulties that the client exhibits, both in the complaints he brings and in those per-
ceived by the psychotherapist. The psychotherapist does not work with the complaint
itself, but seeks to identify the functional difficulties (of which the complaint is one
among several) faced by the client in his problem, conceptualizes them behaviorally
and works with the current CRs that determine them. A client could seek psycho-
therapy complaining of “feeling angry” and “being unemployed”. The psychothera-
pist identifies, however, that the client has several other difficulties: he is overweight
(likely the product of eating improperly and not exercising often), resides with his
parents, and smokes cigarettes. Below we exemplify some of the questions that the
psychotherapist could ask on each topic.
(a) How does the anger (that the client says he feels) manifest itself? What types of
CRs are related to anger? What is the client’s history that is most likely to be
related to feelings of anger? Which events have acquired an evocative aversive
function for anger? What other feelings can be identified in the client’s accounts
and related to the CRs in which he or she is involved?
(b) What types of CRs might be related to the difficulty of employment? What has
the client done to get a job? What might he have done that was insufficient to
keep the job he already had? What could he have done that was crucial to being
unemployed? Is this difficulty related to the former (anger)? In what way?
(c) How does the client feel about the weight? What kind of difficulties faced by
the client can be related to being overweight? Does the client assign an aversive
function to being overweight? What is the eating routine? Has he eaten better in
the past? Does the client enjoy physical exercises? If he does, why doesn’t he
do any? If not, what does he think about sports? What doesn’t he like about
them? Are there any limitations that prevent him from exercising? Does being
overweight limit his daily routine? What limitations are related to him feel-
ing angry?
(d) Has the client always lived with his parents? Has he had an experience living
alone, with colleagues or affective and sexual partners? If so, what were the
difficulties? How about the positive points? If not, what does he think about
leaving home? Has he been able to do so? How does he feel far from his par-
ents? What do parents feel about their children’s presence at home? What do the
client’s age and the fact of being with his parents mean? How does the client
feel about his or her parents? How does it feel to live with them? Does living
with the parents indicate difficulties in interaction and social living? May social
difficulties, if any, have to do with not keeping the job? Are social difficulties
related to the difficulties of getting another job? And with anger?
(e) On average, how many cigarettes do the clients smoke per day? Does the pat-
tern change depending on the day? Does he present any health problems? Does
he have health concerns? What is the client’s goal when smoking? Does the
client intend to quit smoking? Can he restrain himself when he cannot smoke
166 A. S. Aranha et al.

on a particular occasion? Who buys the cigarettes? How did he start smoking?
Has he already tried other substances? Does he still use them? Why does he use
them? Why doesn’t he use them? Does he present self-control in some context?
Does smoking relate to anger, family, weight or unemployment?
The relevant behavioral deficits and excesses, in the sense of producing the difficul-
ties presented by the client, are investigated and hypotheses are made on the occur-
ring CRs. It is the professional’s responsibility, not the client’s, to find evidence for
the hypotheses that have been formulated. By questioning “how do you feel about
smoking?”, the client can answer “pleasure”. It is known that positive reinforcing
consequences strengthen the response that produced them and generate feelings of
pleasure and satisfaction (Skinner, 1986), but it should not be concluded that this is
a positive reinforcing contingency – there are several possible stimulus control that
would evoke the verbal response “pleasure” (Skinner, 1957). We seek behaviors,
thoughts, feelings, and contingencies that strengthen or weaken our hypotheses
(Guilhardi, 2007) because they are compatible or incompatible with the client’s
reports: When he tell us that he smokes to “get satisfaction”, we evaluate whether
the context is aversive; if he says he smokes because of withdrawal symptoms, he
should be able to describe the body states and CRs that elicit the states; when he
says he smokes to get over his girlfriend, he must discriminate what his girlfriend
does that is aversive to him and how he could interact with her in a way that elimi-
nates or minimizes aversive conditions. The professional’s investigation leads to
new client reports that work as discriminative stimuli (SD) for other hypotheses:
smoking to “get satisfaction” suggests a deficit in the repertoire to produce positive
reinforcers; not discriminating the variables on which smoking is a function may
indicate deficit in the self-knowledge; smoking cigarettes “to get distracted” from
the partner may reveal deficits in the escape-avoidance and countercontrol reper-
toire. The investigative process develops hypotheses about CRs and, additionally,
how they interrelate.
After performing molecular contingency analysis, the psychotherapist will be
able to group the identified behaviors into response classes, that is, phenotypically
distinct responses that produce the same effects on the environment and are con-
trolled by the same classes of antecedent stimuli (Catania, 1998/1999). Although
physically different, getting irritated and smoking cigarettes can temporarily elimi-
nate girlfriend behaviors that are aversive to the client. He may feel irritated and yell
at her, which causes her to stop talking, or he may move away from his girlfriend to
go to the smoking area. In both possibilities, he could be being negatively reinforced
and feeling relieved by the removal of the aversive contingency. We would no longer
say that the client gets angry or smokes, but rather that he ineffectually avoids his
partner’s aversive behavior. The accumulation of observations and information
alters or broadens the psychotherapist’s analysis: staying at home without looking
for a job and residing with parents can also be escape-avoidance behaviors of the
difficulties you would encounter in interpersonal relationships (e.g., discussing with
the boss, dialoguing with peers). The psychotherapist should infer and seek clues if
he gets angry, smoking, not looking for a job, and living with the parents are
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 167

responses from the same or different classes. The analysis of molar contingencies
reveals how the client behaves in various areas, such as family, affective, profes-
sional, friendships, etc., making it easier to predict the client’s behavior in the future
and elucidating clinical priorities, i.e., where to start the intervention.
Although people’s repertoire is the result of interactions with the environment
since birth (in the past), problem behaviors are controlled by CRs that operate
exclusively in the present, and the only way to change them is by proposing inter-
ventions in the present. The professional performs an arbitrary cutout of the life of
the assisted to understand it and infers the CRs that control certain behaviors. If the
intervention–based on inference–works, the investigation is suspended. However, if
the intervention is partially or null successful, the psychotherapist will have to re-­
evaluate the case conceptualization. One form of reassessment is the investigation
of the history of contingencies of reinforcement (HCR). Samples of HCR (arbitrary,
such as current CRs) may suggest how the events acquired the stimulus functions
and how behavioral patterns were developed (Guilhardi, 2010a). In the smoking
example given above, assuming that the psychotherapist inferred that smoking was
a possible escape from his girlfriend, the professional might ask himself: what led
the girlfriend’s behavior to be aversive to the client? And how was the pattern of
smoking to escape installed? What was the origin of the difficulties of dialogue in
aversive social interactions, in order to reach a more harmonious relationship? The
answers can be found in the deepening of HCR.
It is important to point out that two clients respond in different ways to the same
CRs (the partner could have a neutral function, a positive reinforcement function,
the avoidance could be different, the response evoked could be of countercontrol,
etc.), not because the CRs evoke different responses in human beings (which would
nullify the laws of BS), but because other CRs (identified or not) are interacting
with the analyzed CR. It is concluded that even if a set of equal contingencies act on
the behavior of two people, the exposure to multiple known and unknown CR in
HCR generated unique people and, consequently, with different psychological treat-
ment needs (Guilhardi, 2010a). Two clients classified as “depressive” do not need
the same care, just as two clients classified as “obsessive-compulsive” are not neces-
sarily in negative reinforcement contingencies. It is necessary to evaluate what has
been classified as “depression” and “obsessive-compulsive disorder” in the case of
clients, i.e., to obtain information on the phenotypes and functions of behaviors that
are emitted or no longer emitted that allow their classification as corresponding to
the diagnostic criteria of depression and obsessive-compulsive disorder.
All the psychotherapist’s interventions must be under control of the conceptual
framework and experimental rigor of BS (Baer et al., 1968). TCR is not eclectic to
these characteristics because it is based on the research methodology and scientific
foundations of the Natural Sciences; monistic conception of human being; behavior
as organism-environment interaction, which is instrumented in the form of CRs;
adoption of the basic attitudes of Science (empiricism, experimental manipulation,
parsimony, etc.); rejection of the mechanistic causal model and adherence to the
Darwinian model of selection by consequences. Problem behavior is reduced by
applying techniques to weaken its emission and, simultaneously, installation of
168 A. S. Aranha et al.

desired behavioral repertoires, which are incompatible or alternative to the

unwanted. The emphasis of the intervention is on the set of procedures aimed at
building desired behaviors (Guilhardi, 2004).
It is essential that the psychotherapeutic procedures are constructed in an indi-
vidualized manner and that the contact of the psychotherapist with techniques
already used (e.g., in the reading of books and articles, in the exposition of clinical
cases) serve as SDs to expand the professional repertoire and increase control over
relevant aspects of the cases and not for replication based on phenotypic, protocol,
or pre-established CR criteria (Guilhardi, 1988). This would put the psychotherapist
under control of rules and make him less sensitive to the CRs present in the thera-
peutic relationship.
Finally, the psychotherapeutic process will be insufficient without the proper
generalization of progress (Baer et al., 1968) and this must be programmed by the
psychotherapist. Desired behaviors installed in the clinical setting should be gener-
alized to three areas: 1) other behavioral classes, so that the client’s development is
amplified in multiple areas of his life; 2) diverse daily environments (home, school,
work, leisure, social interactions) and not restricted to progress in the therapeutic
context; and 3) changes should be lasting and extend over time. Only when the cli-
ent demonstrates that he has incorporated the three areas of generalization into his
repertoire will the intervention have been successful.

Substance Dependence

Substance dependence is the usual nomenclature for problems with consumption of

PAS (Diehl et al., 2011), with the main characteristic being the pattern of drug use
despite the adverse consequences that the use causes. The health area usually uses
the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) as a reference because, although they do not describe the etiology of the
problem, they facilitate communication between professionals. In its fifth and latest
edition (APA, 2013), the manual performs the diagnosis of Substance Use Disorder
(SUD) depending on the number of criteria identified in the client over a 12-month
period. Two or three criteria suggest a mild disorder, four or five a moderate disor-
der, and six or more severe. The diagnostic criteria are shown in Table 12.1.
The TCR does not use the diagnostic criteria of manuals for assessing substance
dependence (in fact, any behavior classified as psychopathological) because it con-
siders them phenotypic (“unsuccessful efforts to control use”) or molecular (“use
resulting in failure to play important roles at work”) and does not specifically refer
to any individual. People classified with SUD, like any client, have a wide reper-
toire, with functionally different behaviors, and we should interpret them individu-
ally in the light of BS. The difference is the inclusion of the behavior of consuming
PAS in the psychotherapist’s analysis, but the analysis is not restricted to this
behavior.
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 169

Table 12.1 Diagnostic criteria for substance use disorder

A. A problematic pattern of substance use, leading to clinically significant impairment or
distress, as manifested by at least two of the following criteria, occurring within a 12-month
period:
Impaired control
 (1) The substance is often consumed in larger amounts or over a longer period than was
intended.
 (2) There is a persistent desire or unsuccessful effort to cut down or control use.
 (3) A great deal of time is spent in activities necessary to obtain, use or recover from their
effects.
 (4) Craving, or a strong desire or urge to use drugs.
Social impairment
 (5) Recurrent use resulting in failure to fulfill major role obligations at work, school, or
home.
 (6) Continued use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by their effects.
 (7) Important social, occupational, or recreational activities are given up or reduced because
of use.
Risky use
 (8) Recurrent use in situations in which it is physically hazardous.
 (9) Use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by use.
Pharmacological criteria
 (10) Tolerance, as defined by either of the following:
 (a) A need for markedly increased amounts of substance to achieve intoxication or desired
effect.
 (b) A markedly diminished effect with continued use of the same amount of drug.
 (11) Abstinence, as manifested by either of the following:
 (a) Characteristic abstinence syndrome for specific substance.
 (b) Substance is taken to relieve or avoid withdrawal symptoms.
Source: Adapted from “Diagnostic and Statistical Manual of Mental Disorders” (APA, 2013, p. 491)

The behaviors of thinking about, “feeling like”, planning the purchase, seeking
and consuming PAS are conceptualized as a set of respondents and operants who
respond to the laws of BS, adding the specificities of the stimulus functions of PAS
(the TCR defends that the respondent-operant distinction is purely didactic and that
in real life behaviors always occur inseparably). In respondent relationships, PAS
have the function of unconditioned stimuli, which elicit two types of unconditioned
responses: the pharmacological effects of the substance (e.g., cocaine makes the
user feel “energized” and “euphoric”) and the compensatory effects linked to the
body’s homeostasis (e.g., in abstinence cocaine leads to fatigue and depression).
The neutral stimuli (e.g., money) that are paired with the drug become conditioned
stimuli that elicit the aversive compensatory effects, which we call withdrawal syn-
drome (it is worth remembering that the withdrawal is not essential for a compulsive
pattern to occur). Consumption in contact with conditioned stimuli increases the
compensatory effects leading to tolerance, i.e., the need for a greater volume of
substance to experience the same effect (Benvenuti, 2004).
Consuming SPAs are operants controlled by antecedents and consequents. The
reinforcing consequences are the pharmacological effect of the substance (e.g.,
170 A. S. Aranha et al.

drinking beer and being “cheerful”), social reinforcers (e.g., approval of a group),
and conditioned reinforcers (e.g., when the substance is initially neutral or aversive
and becomes reinforcing by pairing with social reinforcers). Consuming substances
can also be maintained by negative reinforcement (e.g., removal of withdrawal and
other aversive CRs). The antecedents are SDs and pre-aversive stimuli related to
consequences (e.g., places of use and conflicts, respectively) (Miguel et al., 2015).
It is essential to know the characteristics of PAS that differentiate them from
other environmental stimuli. Skinner (1989) conceptualized them as anomalous
reinforcers stimuli that differ from primary reinforcers. Some distinct characteris-
tics of PAS are the immediacy and magnitude of the effect (no event produces such
intense changes in the body), the low cost of response to intoxication (e.g., the effort
to become a skilled sportsman is superior to the ritual of crack, but with a less
intense effect), the lack of satiation mechanisms (e.g., the first chocolate is deli-
cious, but the tenth is aversive. The tenth zip of cocaine may be less reinforcing than
the first, but not aversive to the point of the user giving up on aspirating it), the aver-
sion to deprivation (abstinence syndrome) and deleterious alterations in the nervous
system of the organism (Garcia-Mijares & Silva, 2006; Heyman, 1996).
Having said that, what is the psychotherapeutic process of TCR with clients who
consume SPA? As advocated throughout the text, the inquiry is wrong to suggest
that there is a type of abusive client or a pattern of substance dependence and con-
tingencies of reinforcement therapists should explain what they do with these cases.
TCR does not use pre-defined protocols and techniques, but works with concepts
derived from BS to assess idiosyncratic affective and behavioral problems. It is pos-
sible that the clients have some similarity in the complaints and difficulties that
bring them to clinic; however, homogeneity in the evaluation and treatment is not
justified. For example, two clients seek psychotherapeutic assistance and present
“alcohol and cocaine consumption”. The psychotherapist could raise the following
questions:
1. Did they seek help because they considered consumption problematic? Or did
they look for other reasons and the psychotherapist identified the consumption?
If they are worried about how often they are using PAS, what consequences are
aversive and have motivated them to seek psychotherapy?
2. What are the functions of consumption? What are the maintenance conse-
quences? What are the expected consequences? What are the antecedents that
evoke the use of the substances?
3. What are the HCR that have installed the patterns of drug abuse? Which CR have
made individuals vulnerable to the pharmacological effects of drugs? Which CR
led to a preference for one drug or another?
4. What are the behavioral deficits and excesses related to drug use? What are the
behavioral deficits and excesses in the clients’ global repertoire?
5. What are the family members’ behaviors toward consumption? What about other
customer behaviors? Do they support treatment or not? How do they support it?
What are the rules and self-rules about user behavior?
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 171

6. Do clients want to stop using drugs? Decrease the consumption? Interrupt a type
of substance? Interrupt for a period of time? In the psychotherapist’s evaluation,
should they stop, decrease, continue or interrupt? Why?
7. What is the academic background of the clients? Work? Housing? Spouse?
Children? Income? Plans? Resources to be treated?
By answering these questions (and many others), the psychotherapist will realize
the clients are different and they only resemble each other superficially. Although
they have in common the consumption of PAS (even if they are identical drugs), the
way each one has interacted with the physical and social environment since birth,
the HCR with the substance until now and the CRs in the areas of family, affective,
professional relationships, etc., are unique. Thus, the professional will use the philo-
sophical and conceptual aspects that govern human behavior (the laws of BS, these
are the same for all of us), taking into consideration the specificities of PAS (briefly
described in the chapter, however not exhaustively) to understand the learning his-
tory (unique to each client) that built them in a way that led to the abusive consump-
tion of PAS, maintained the functions of the stimuli and their behavioral repertoires
over time and led them to psychotherapy.
It is worth highlighting the importance of HCR to understand why a minority of
people use PAS and experience serious problems, such as those found in rehabilita-
tion clinics and psychosocial care centers. The moderate individual may drink
alcohol on Saturday and “waste” Sunday with the hangover, but will probably be
under the control of the likely punishments, such as not working, if they risk get-
ting drunk during the week. The individual considered “dependent” can drink
every day and lose his job, not try to relocate to the job market and start living on
the street. It is essential to analyze which CRs affect different people and lead them
to problematic consumption. The man who does not abstain from consuming crack
in order to find a job the next day may respond excessively under control of imme-
diate consequences; the woman that does not respond to the probable punishments
of drunk driving may be insensitive to the natural aversive consequences; the per-
son who consumes despite the family fighting and her child being hurt may be
insensitive to the social consequences (Aranha & Oshiro, 2017). The reasons of
exemplified clients to respond in a certain way to present CRs are specified in
their HCR.
As described in the previous section, the TCR intervention aims to increase the
frequency of desired behaviors (primarily) by applying procedures for installing
and strengthening the repertoire, and to decrease the frequency of problem behav-
iors by applying weakening techniques (Guilhardi, 2004). The psychotherapist
must directly attack the respondents and operants of drug use: make the user aware
of his physical and psychological condition, identify the CRs that maintain the
consumption and change them in the desired direction, develop alternative and
incompatible behaviors that produce positive reinforcers and eliminate aversive
stimuli without relation to drugs, become sensitive to other reinforcements
172 A. S. Aranha et al.

possibilities, etc. (Guilhardi, 2010a, b/2013). The therapist by contingencies of

reinforcement, as with any client, also evaluates the CRs related to the problems
identified, in this case the self-administration of PAS: the characteristics exempli-
fied in the previous paragraph, such as impulsiveness and insensitivity to social and
natural consequences. And, in addition, the professional evaluates other compre-
hensive repertories that have no clear relation with consumption: the client is a
human being with a history, difficulties, values, and dreams of his own before a
drug user.
The programming for generalizations of psychotherapeutic advances with sub-
stance dependents involves at least three groups of procedures: 1) systematic coun-
seling of the user’s family (Hunt & Azrin, 1973). This social and affective microcosm
is important in the process of generalizing progress in particular because it has
almost always participated (consistently or not) in the initiation and development of
the process of substance dependence; 2) techniques of self-control (Harris & Miller,
1990) and self-knowledge (Sobell et al., 1976). It is not enough for the other person
to participate, without the necessary and proper responsibility and engagement of
the user; and 3) therapeutic companions who can use fading, modeling procedures,
etc., so that the behaviors are emitted and strengthened in the natural environment
(Balvedi, 2003).
Below, we illustrate the psychotherapeutic process of TCR with PAS with a clini-
cal case. As previously mentioned, it is hoped that the case concept and psycho-
therapeutic strategies are not replicated as indiscriminate techniques (Guilhardi,
1998), but serve as SDs to enrich the repertoire of the psychotherapist in the very
cases he/she attends. We suggest reading Guilhardi (2010/2013) as an additional
source of SD for better observation of clients involved with PAS.

Clinical Case

Client Identification

Mélvio34 (29) was the youngest son of Jesus (70) and Pureza (70), and brother of Ivo
(39). He began several undergraduate5 courses, concluding none. When he sought
psychotherapy, he was unemployed and participating in several selection processes
and, after three weeks, he obtained a position in a technology company. He was in
a stable relationship with Raissa (28).

3
All the names used in this chapter are fictitious.
4
Production of the text began after the client signed the Free and Informed Consent (TCLE).
5
Information which compromises the confidentiality of the client and the persons involved has
been omitted.
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 173

Complaint

After collecting preliminary information, the psychotherapist asked why Mélvio

sought psychological care and he replied: “I came because I have horrible anxiety
attacks. I have been panicking for years. I feel that I’m going to die, that my veins
are clogging up and I’m going to have a heart attack”. The client sought psychiatric
and psychotherapeutic treatment previously, but was unsuccessful – the anxiety cri-
ses have continued over time. The first crisis had occurred six years before psycho-
therapy began, when he became unemployed. Mélvio had obtained a position in a
multinational company and, when talking to his superiors, he had the “impression”
that they “liked him”. In the same week, at a happy hour after work, the client got
drunk and offered cocaine to his bosses. He was fired the next day.
The psychotherapist was brought under control of drug use and advanced the
questions in this direction. The client reported, “I was two people. From Friday to
Sunday only parties, but during the week I was good. I had two personalities and I
didn’t even think about it, but then you start to see yourself with time to think and
then you get depressed (…) the personality that is not nice… I drink and send mes-
sages (laughs), I snort cocaine, I make a mess, I go after women”. The client has not
established any relation between anxiety complaints and the consumption of alco-
hol and cocaine.
In addition, Mélvio’s verbalizations had as main themes anxiety complaints,
drug use, and interpersonal behavior with bosses. The following questions (private
responses) sought to explain the functions of such behaviors by the
psychotherapist:
Anxiety: what exactly was the anxiety he experienced? If the term “anxiety” is being
used correctly by Mélvio, which aversive stimuli would he be responding to? Did
the first anxiety crisis occur after being unemployed? Did the other crises occur
in similar contexts? Or different contexts?
Realizing the bosses liked him and offering drugs: how did the client “realize” the
bosses “liked him” in so little time? What did the bosses do? Does the client
believe other people like him too? Even if the bosses had identified with the new
employee, why did Mélvio believe using drugs with his superiors would be
something reinforcing for them? Did he think about the possible consequences
of his behavior on the bosses and their future in the company?
Drug use: what is the client’s use pattern? That is, how many times a week does he
use it? In what quantity? What contexts evoke consumption? What are the main-
taining consequences?
The psychotherapist was also under control of other variables besides anxiety,
interpersonal relationship, and drug use of the client that could give “tips” on the
target contingencies of reinforcement:
Age of parents and difference from his sibling: the client’s parents conceived him
over 40 years old and 10 years after the birth of his brother. What led them to
this? Was it a conscious decision or did they not use contraceptive methods?
174 A. S. Aranha et al.

What are the rules and self-rules about having and raising children? How has the
behavior of parents affected and continues to affect Mélvio’s repertoire?
Undergraduate courses: What led the client to attend colleges and not complete
them? Did he choose the courses or was he forced to take them? Forced by
whom? If so, what were the criteria used?
Unemployment: How did he lose his job in the other times? Was it because of his
own behavior or not? What is his professional repertoire like when he is
employed?
Affective Relationship: How long has he been with Raissa? What is the relationship
like? Does the girlfriend’s behavior influence in any way the difficulties
presented?
Behavioral excesses that produced social and physical risks: Were drug use and
offering drugs at work (leading to dismissal) the only reckless behaviors the cli-
ent emitted? Would the different behaviors have the same function? Did he emit
risky behaviors? Which ones?
The contingencies of reinforcement therapist identifies, in the verbal and non-­
verbal behavior of the client and the people relevant to the psychotherapeutic pro-
cess, inside and outside the session, as many deficits, excesses, and desired behaviors
as possible. It raises hypotheses about the contingencies that control the behaviors,
looks for information that validates or refutes its hypotheses, and groups the various
behaviors into response classes. Knowledge of the client’s behavioral patterns in
multiple contexts and the interactions of the present contingencies enable the cre-
ation of psychotherapeutic goals (where one wants to go) and procedures that attack
the target contingencies (how to get there) (Guilhardi, 2004).

Behavioral Characterization of the Client’s Difficulties

Initially, five main difficulties were identified in the client’s repertoire. The session
vignettes illustrate the problem behaviors occurring in different contexts. Because it
is the same client, it is expected the examples contain overlapping, i.e., the verbal-
izations demonstrate more than one difficulty.
1. Excessive behavior under the control of immediate positive reinforcers to the
detriment of delayed aversive consequences.
Examples of verbalizations:
Food: “I eat too much, I drink”, “I ate too much yesterday. A lot. I overate. Then I
can’t sleep because I’m feeling sick.”
Finance: “I spend a lot. I have to work to pay for my stuff. I have bad credit. I don’t
have a credit card. Raíssa lends it to me. If I get unemployed… I don’t even want
to think about it!”
Alcohol and drugs: “I drink reasonably. I drink a lot. I don’t have a drinking prob-
lem. If I decide to stop during the week, I can”.
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 175

The psychotherapist identified that a significant portion of Mélvio’s repertoire

was under control of immediate reinforcing consequences, despite putting Mélvio’s
social and physical integrity at risk. He frequented nightclubs until dawn, spent too
much money, and drove in such a way as to cause automobile accidents. Specifically
in relation to alcohol and cocaine, with the course of the sessions he admitted that,
after starting the consumption, he felt difficulty in interrupting it. In this way, he
used primarily on weekends (Friday, Saturday, and Sunday) to avoid professional
problems (working under the influence of drugs, being fired). To be able to use on
workdays, he prepared himself to mitigate the damage (e.g., work in home office).
2. Excessive countercontrol behavior in contingencies which would not have
immediate reinforcing consequences.
Examples of verbalizations:
Psychiatrist: “Yesterday I had a crisis, I called him [psychiatrist] and he didn’t
answer me. I’m not going there anymore, because I think that is inattention”.
Girlfriend: [when girlfriend tried to break up] “you wanted to break up. When we’re
not together, you won’t know where I am either anyway”.
Psychotherapist: “I don’t agree very much [with the psychotherapist’s analysis], I
thought about not coming anymore, because I think the Behavior Analysis is
shallow. This thing of “I did this” or “I didn’t do that”, I don’t think it works
very much. I want to understand in depth, it’s not deep”.
Mélvio was emitted countercontrol behaviors with an aversive function to others
when the social environment did not reinforce his behavior in the way he expected.
At the beginning of psychotherapy, the psychiatric medication did not ease the anxi-
ety, which led the client to change professionals. The new doctor managed anxiety
attacks by responding quickly to Mélvio’s messages; however, as a result of the
symptoms decreasing, he started not to respond frequently. Frustrated, Mélvio
reported thinking of giving up treatment, despite the stability of his condition. He
also considered giving up when he was told to stop drinking and when his sugges-
tions about changing his medication were not heard. The same difficulty occurred in
the intimate relationship. When Raíssa said she would like to break up the relation-
ship, claiming she could no longer cope with her boyfriend’s relapses and behavior
problems, and did not reconsider breaking up despite Mélvio’s requests, the client
behaved in ways previously described as aversive by her partner, going out to drink
without telling her and disappearing for long periods.
Such behavior also occurred in the psychotherapeutic relationship. In a session
in which they were analyzing how his girlfriend felt about the client’s behavior,
Mélvio said he disagreed with the professional’s interpretation of the situation. In
the next session, he suggested to interrupt the psychotherapy. It is possible that this
attempt to negatively punish the professional’s behavior was another example of the
countercontrol commonly emitted by Mélvio in interpersonal relationships.
176 A. S. Aranha et al.

3. Excessive feelings and behaviors of distorted self-esteem and self-confidence.

Examples of verbalizations:
Musical performances: “When I go up on stage, I kick ass. The crowd raves.”
Physical: “I’m fat. I have to lose weight. If I get thin, I’ll be unbeatable. I don’t know
if I’d end up with Raíssa then.”
Professional: “I wonder how they see me? I’m well rated. The s*** is when I have
to explain myself. I didn’t finish college.”
The client was under the control of self-rules that described components of his self-
esteem and self-confidence in a disproportionate fashion in relation to the contingen-
cies, despite the social deterioration that following the self-rules causes. The client
concluded “I’m the best, that’s why I’m adored,” disconnected from what he did and
the moment he did it. Playing in his band was “being the best” (independent of people
liking the music), he thinks that he was able to date the girl he wanted (unaware of the
determinants that would lead his partner to feel attracted to him) and, in the work
context, he reported being a good professional independent of what the bosses thought
of him (not having finished college could change the boss’s opinion, despite this, he
believed he was good “even so” and it was “the boss who wasn’t seeing him right”).
4. Deficit in responding discriminatively under the control of contingencies that
affected third parties.
Examples of verbalizations:
Girlfriend: “if I don’t want to go out with her [girlfriend], she understands well: [and
tells me] ‘go drink and come back’. She knows I don’t like to get stuck at home”.
Mom: “I didn’t go to the hospital to see my mother, I needed to clear my head
because the week was heavy and I went to the bar”.
Colleague at work: “He came for an internship and I taught him everything. Now he
got the job, he goes out for happy hour and doesn’t invite me. He created his own
gang and I’m out of the group.
The client did not consider how his behavior would affect people’s feelings and
behaviors. He would rather go to the bar than stay with his girlfriend who was sad
at home, or visit his mother who was in a serious health condition at the hospital. In
addition, Mélvio also showed difficulty in analyzing the CRs that controlled the
behavior of others. He usually expected the other to behave in a reinforcing way
(strengthening the friendship, for example), even if the previous interactions did not
justify such a relationship. For example, he helped a colleague at work – only once –
and felt angry when he found out he hadn’t been invited for the night out.
5. Deficit in the repertoire to identify and describe the contingencies that controlled
bodily states with aversive function.
Examples of verbalizations:
Anxiety: “the crisis comes from nowhere”, “just like that: ‘I’m fine’. Then my heart
begins to tachycardize”, “am I going to die? My fingers are numb, my chest fails.
I think it’s because I had rib at lunch and I feel my veins clogging up.”
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 177

The client reported chest pains, numbness, and fear of dying during the sessions
and by WhatsApp messages. At certain times, he did not relate anxiety to environ-
mental events, and at others, he related to immediate events disconnected from HCR
and present CR.

Desired Behavior

In psychotherapy, Mélvio behaved with cordial phenotype, assiduity, and interac-

tions with possible positive reinforcement function for the psychotherapist. In the
professional context, he responded discriminatively to the stimuli to perform the
work activities with good performance. With friends, he had a repertoire of subjects
related to history, music, and general knowledge.

 istory of Contingencies of Reinforcement (HCR)

H
and Behavioral Conceptualization

The behavior of family members is relevant to understand how the events acquired
the stimulus functions and how the client’s learned his behavioral patterns (Guilhardi,
2010a). Jesus and Pureza celebrated when Mélvio was born. The client said “the
expectation was that I would be a great man”. Pureza suffered several miscarriages
between the birth of his brother Ivo and the client (that is why Mélvio was born
later). The previous losses made the parents sensitive to aversive stimulation that
came in contact with their son’s behavior (other variables in the parents’ HCR must
have contributed to the high sensitivity to Mélvio, however it would be necessary to
evaluate them), making free reinforcement (noncontingent reinforcement) the most
important CRs in Mélvio’s childhood. Free reinforcement occurs when a stimulus
with a reinforcement function (a stimulus with properties of strengthen responses
that produces it and elicit pleasant feelings) is presented independently of the sub-
ject’s behavior (Guilhardi, 2018). Mélvio was exposed concomitantly to four
classes of CRs:
(a) Mélvio received social and tangible reinforcements that were not contingent on
pre-established desired behaviors (the relationship of the parents with Ivo was
different, strengthening the hypothesis that there was a change, at least partial,
in the parents’ repertoire with Mélvio’s birth). The client could go out with
friends and earned objects of interest regardless of what he was doing: “the
relationship [with parents] is very good. They gave everything to me”;
(b) Mélvio received contingent tangible reinforcements upon requests (mands),
such as money and travel: “nobody in the family had what I had. I was the first
to travel”;
178 A. S. Aranha et al.

(c) When he emitted behaviors under the control of immediate reinforcers, but
which produced aversive consequences for others, there was a scarcity of social
aversive consequences (and eventually positive reinforcers in the form of atten-
tion and concern). One year, Mélvio did not attend Jesus’ birthday: “I apolo-
gized. He did not say anything. The next year he says: ‘take care, beware!’.
Nobody says anything. Everything is ‘under the carpet’ in my house”;
(d) When he emitted behavior under the control of immediate reinforcers that pro-
duced aversive consequences for itself, there was a lack of presentation of social
aversive consequences (e.g., he was not censored), and on the other hand, he
was protected against aversive consequences. In a situation where he had
crashed his car, “he [father] was very worried and said that the most important
thing is my health”.
The contingencies of reinforcement in this period of Mélvio’s history are shown in
Table 12.2.

Table 12.2 Contingencies of reinforcement at Mélvio’s HCR. In the first two, positive
reinforcement is released freely or contingently on mands. In the latter two, the behavior produces
aversive consequences for himself and others, but the verbal community reduce or eliminates
stimulation
Antecedents Responses Consequences
Family environment Absence of pre-­ Short term Long term
Discriminative selected behavior by Positive reinforcers: Absence of
stimuli: parents (emission of Social (family): Praise consequences
Permission to any behavior) (e.g., “you’re the
behave in any way man”), money, concert,
Melvio wishes tours
(“What are you Mands (e.g., “I want Positive reinforcers: Absence of
gonna do today, to go to the show”, “I Access to shows, items consequences
son?” “what do you want a guitar”) of interest, money, trips
want from us?”)
Behavior that would Positive reinforcers: Possible positive
produce reinforcers Social contact punishment: Father gets
for Melvio and hurt
aversive stimulation Positive reinforcement:
for others (e.g., going Father says “the
out with friends and important thing is the
not going to Dad’s son being well”
birthday)
Behaviors that Positive reinforcers: Possible positive
produced short-term Automatic reinforcers, punishment: Automobile
reinforcers and unconditioned and accident
long-term aversive conditioned reinforcers Negative reinforcement:
stimuli (e.g., run with (e.g., speed, social The father removes the
the car) approval for risky aversive stimuli from the
behavior) environment, takes care
of Melvio, asks if he is
safe
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 179

The behavioral results of the contingencies in Mélvio’s repertoire were:

Superstitious Behavior Mélvio began to establish superstitious relationships
between his behavior and the events of the environment that followed. The parents
released reinforcers and eliminated aversive stimulation regardless of how the client
behaved (Guilhardi, 2018), facilitating the formulation of self-rules like “regardless
of what I do, they like me” (specifically on social reinforcers, the client said the
father was the most affectionate figure, while the mother was distant: “she is depres-
sive. It gives me a bad time to stay close”). The self-rule is superstitious in the sense
that does not apply to all of Mélvio’s interpersonal relationships – not everyone
would like him or protect him regardless of how he behaved.

Feelings of Self-confidence Restricted to the Family Environment Feelings of

self-confidence emerge when an individual emits a response that produces positive
reinforcers or eliminates aversive stimuli (Guilhardi, 2002). The person feels that
they have a repertory available to produce what they want. Mélvio went through a
history in which asking for reinforcers was strengthened by his parents, but they did
not necessarily manipulate CRs that built behaviors that, if emitted, would result in
the expected consequences. In this way, self-confidence became circumscribed to
the social environment in which Mélvio was. Close to the family, he feels he “can
have it all” (I desire everything and I feel I can have it, because someone will give
it to me); “far from the family, I feel insecurity”. The passage elucidates the feelings
of low self-confidence when Mélvio was away from his family: [therapist asks what
will happen when his parents pass away] “When I have a problem, my father is there
(…) I always wanted to be independent, not to become a beggar. I put my life in
them [parents]”.

Distorted Feelings of Self-esteem Long-lasting feelings of self-esteem occur

when the subject a) has developed feelings and behaviors of self-confidence, i.e., has
a repertoire to produce positive reinforcers and eliminate aversive stimulation with-
out help from others and b) has access to noncontingent social reinforcers to any
pre-established behavior by the community (Guilhardi, 2002). The exposure to both
CRs guarantees the affective and behavioral health of the individual: self-­confidence
without self-esteem generates a competent human in the activities, but who does not
feel the affection and consideration of the other; self-esteem without self-confidence
generates an insecure or unprepared arrogant when away from the group (Guilhardi,
2018). Mélvio was exposed to free reinforcements that produced distorted feelings
of self-esteem, because without the adequate repertoire of self-­confidence, he was
dependent on the other to feel loved. Despite reporting that “I am the man”, he felt
bothered when his mother did not pay attention to him (as previously mentioned,
“it’s a bad thing to stay close, she’s depressive”) and, in the adult stage, when his
friends did not recognize him. He felt special without realizing that when the agency
releasing reinforcements was not present, he was no longer special.

Sensoriality Because the parents arranged reinforcements unrelated to their chil-

dren’s actions, Mélvio was not strongly deprived or aversively stimulated, ­becoming
180 A. S. Aranha et al.

little sensitive to certain types of reinforcements (there were no establishing opera-

tions that updated the reinforcement function of some events). Thus, there were
restricted possible reinforcements Mélvio could respond to in the future. An HCR
without important establishing operations (EO) tends to create individuals that are
sensitive to reinforcers related to bodily sensations (drugs, fear, danger) (Skinner,
1975). Mélvio, therefore, was more likely to respond to intense reinforcers that
would guarantee him some immediate sensation (alienated from the fact that it
could be harmful in the medium-long term).
TCR makes a distinction between sensorality and sensitive feeling behavior
(Guilhardi, 2012). Sensoriality behavior refers to respondent and operant responses
elicited and evoked by antecedents, mediated by the sense organs (hearing, sight,
etc.) and which are maintained by the consequences they produce for the subject
who emits them and not by the consequences they produce in others. The anteced-
ents and consequences must be present, making the control immediate and direct.
For example, a client could steal money from the family to buy drugs, regardless of
whether the parents are upset (“I spend all my money, I need to get more”). The
parents’ sadness would only be aversive if it bothered the client (“I have to find a
way for them to stop bothering me”). Sensitive behavior is not elicited and evoked
by antecedent stimuli, but by the function that the verbal community attributes to
the stimuli and is maintained by the functions the consequences have for the other,
not for the one who emits the behavior. The antecedents and consequences do not
necessarily need to be present, being conditional signs satisfactory. For example, by
manifesting withdrawal, a client could feel guilty before trying to steal his parents
(“I can’t steal money again, I’ll hurt my parents”) and eliminate what is aversive to
them (“I need to recover, not for myself, but so that my father and mother stop
suffering”).
Imprudence We call “courageous” behavior likely to produce reinforcers and
aversives when the subject has a repertoire to handle aversives (e.g., a radical sport)
and “reckless” when they produce reinforcers and aversives, but without the ability
to handle the risks or they are disproportionate (e.g., betting all savings on roulette)
(Skinner, 1989). Mélvio emitted behaviors that produced punishments attenuated
by his parents. This meant that the antecedents of the behaviors did not acquire
discriminative stimulus functions for punishment (SDp), because there was no
respondent pairing between the behaviors, the environment, and the aversive stim-
uli. Mélvio started not to discriminate pre-aversive stimuli, did not learn effective
escape-avoidance behaviors, and maintained the emission of reckless behaviors.

Impulsivity and Low Frustration Tolerance Mélvio had access to reinforcers

because he “existed” and when he asked for them, without having to behave to pro-
duce them. In a constructive social environment, the CRs are programmed so that
responses produce gradually delayed consequences, with some response cost, in
intermittent reinforcement schedules, with mild aversive consequences, creating
behavioral persistence and frustration tolerance (Guilhardi, 2019). The result of this
particular HCR in the client’s repertoire was excessive control of immediate
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 181

c­ onsequences and less control by delayed consequences (Rachlin & Green, 1972)
and low frustration tolerance (if the reinforcer did not occur immediately, there was
no behavioral variability to achieve it and an emotional explosion occurred). He also
believed that the other should guarantee his privileges and didn’t accept privations,
reinforcer delays, or demands for desired behaviors.

Affective Indifference In the most relevant CRs in Mélvio’s HCR, his parents had
an SD function to ask for social and physical reinforcements and, to some extent,
reflexive establishing operations to require if privileges and admiration were not
guaranteed (Guilhardi, 2018). Mélvio did not have to learn to pay attention to feel-
ings (“my father is sad”) and behaviors of others (“he doesn’t want to give me
money”) and to analyze the CRs that could have caused the change (“it must be
because I didn’t go to his birthday”). What the other felt and why he felt wasn’t
important, as long as “his” reinforcements weren’t reduced or curtailed.

Deficit in the Self-knowledge Jesus and Pureza were under control of ensuring
reinforcement independent of what the son was doing and they did not ask questions
with SD function for Mélvio to pay attention to his own behavior and what con-
trolled it (Skinner, 1953). The client was primarily under the influence of what he
felt: the essential thing was to do to feel good, not to understand why he felt good,
and to do not to feel bad, without understanding why, for him, that was bad
(Guilhardi, 2018).
Throughout the client’s history, the procedures used by the parents with Mélvio
interacted with new contingencies in the activities outside home. In adolescence, he
presented low performance at school, since studying had a high response cost (low
frustration tolerance), low magnitude reinforcers (sensoriality) and family did not
present differential consequences for desired and unwanted behaviors in the school
area. He started to spend time with colleagues who also had educational problems
and valued other subjects, such as music and nightlife. Mélvio began to identify
himself with the themes proposed by the group, which guaranteed him access to
social reinforcements in the form of attention (sensoriality and distorted
self-esteem).
The routine with the group went beyond the scope of the school and moved to
bars, shows, and nightclubs (entertainment maintained financially by his parents).
The environments were functionally similar to the familiar, where the client had
social reinforcements (he could be “important”), not being required to do anything.
In this underground context, he met PAS, especially alcohol and cocaine. Drug use
was initially maintained by the social impact it caused (“he is the craziest of the
group!”, “he plays guitar even if he is drunk”) and the frequency and intensity grad-
ually increased so that he would not be “just like the others” and would continue to
stand out.
Upon finishing school, Mélvio entered several colleges without completing any.
His low frustration tolerance did not allow him to attend classes every evening,
concentrate for up to four hours/class, do assignments, study, etc., at the same time
182 A. S. Aranha et al.

he did not have access to social and pharmacological reinforcements with his friends
at night. He gave up the courses because of the difficulty in emitting a high fre-
quency of responses that did not lead to the immediate and intense reinforcers to
which he was more susceptible.
His father retired at the end of school and the family changed their financial situ-
ation. The maintenance of expenses for Mélvio’s was suspended. The client, in the
imminence of the deprivation of such reinforcements, sought work in his area of
interest (he wouldn’t do something he didn’t like) and got a job with a friend, work-
ing informally. Later he got a position in a company, the moment in which com-
plaints of relationship difficulties arose. The group’s demand had changed: it had
moved from the underground environment (and in the previous work, a tolerant
environment for working with a friend) to a professional environment, where he
lived with diverse subjects and without focus on a style of music or tours. At this
moment, the client developed “two lifes”: during the week, he lived with the depri-
vation of reinforcers (for not having a repertoire to produce them in a different
environment), and on the weekend, he had the life he had built since high school
(drugs, rock, attention). He kept working exclusively for the money that financed
the weekend and, consequently, the social reinforcers.
An addendum. It is interesting to realize that the inability of the father to pay has
possibly led to a different outcome than if the father continued working and did not
want to pay for his son’s pleasures. In the second hypothesis, Mélvio could have
thought “they are not giving what is rightfully mine”, “they are petty”, etc. The story
would have been quite different and the problems would probably have concen-
trated on the relationship with the family (Guilhardi, 2018).
As time went by, Mélvio became more and more deprived, as his interpersonal
repertoire at work was not effective and he could not go out as he would like during
the week. He also began to get more under control of the pharmacological effects of
drugs (not only the social reinforcers), since consumption had a low response cost
and produced intense body sensations (sensoriality), increasing the frequency on
weekends and causing serious problems (e.g., car accident), but without worrying
him (imprudence). Progressively he left aside activities that were not related to use
(e.g., sports).
In the places where the client transited, problem behaviors were not only
accepted, but susceptible to be admired. Thus, despite the fact that such repertoire
presented itself as unwanted by certain groups of the conviviality (which not only
deprived him, but also annoyed him), it continued to produce social reinforcers,
preventing him from becoming aware of his difficulties: it were certain people who
did not understand his “relevance” and “eloquence” for playing, using drugs and
talking about “different” subjects and not him, the result of his HCR, who was the
slave of the reinforcers who kept him in this fantasy and restrictive role. The cycle
did not foster the development of problem-solving skills, the production of feelings
and behaviors of responsibility and self-control, and greater behavioral variability
to deal with people with other interests.
Once, during a company happy hour, deprived of reinforcers, he used the avail-
able repertoire to get attention. He drank too much, used cocaine, made bad jokes,
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 183

and offered drugs to others. The next day he was fired. It was the first time that the
environment signaled a behavior as undesirable, and later he was able to experience
real deprivation without the salary. The event caused the first anxiety crisis. Mélvio
was under control of the consequence (loss of employment), but not under control
of previous stimuli to avoid the emission of certain responses in the future, repeat-
ing the same path throughout his life: in deprivation, he did not identify the anteced-
ents or undervalued his pre-aversive function, continuing to use drugs and behave in
an unwanted way.
The respondent conditioning among PAS and professional losses made the
effects of drugs conditioned stimuli that elicited fear and anxiety, referring to the
losses of social and financial reinforcers. Let us remember that the lack of money
and the hindrance of nightlife were extremely aversive to Mélvio due to his HCR:
far from the group he was nobody (low self-esteem) and had no competent reper-
toire (low self-confidence). Besides, the anxiety bothered a lot (sensoriality) and led
to catastrophic conclusions like “I’m going to have a heart attack” (low self-­
knowledge). Thus, with a double life where he was only fully satisfied in periods of
the week, with panic attacks and catastrophic thoughts, without knowing why he
felt anxiety and without self-criticism of his behavior pattern, Mélvio sought psy-
chotherapy. What about affective relationships? Dating in general was superficial
and involved people who valued the “hipster”, musical and film repertoire. The
phenotype was “the best boyfriend in the world” and “the most f****** couple in
the club”, to impress the girlfriend and the group. Unlike his parents, the women
with whom he was related deprived him of attention, charged him, demanded, criti-
cized him, which evoked the repertoire of countercontrol with aggressive pheno-
type. It was as if Mélvio thought “I want to be loved and important, and I do
everything in your direction so that you reinforce my behaviors, but I don’t want to
behave to really reinforce your behaviors or lose reinforcers for you to be happy”.
At the beginning of psychotherapy, self-observation and changing the interpersonal
repertoire were not priorities for the client.

Goals

Taking HCR into account and the identification of problem behaviors, the psycho-
therapeutic goals for Mélvio’s case were:
• Making the client able to respond discriminately to occurring CRs (he did not
know that he exaggerated with drugs and emitted unwanted interpersonal behav-
iors due to his HCR and that anxiety was a product of the problems identified).
• Make the client sensitive to the others.
• Propitiate the client to tolerate aversive conditions (frustration tolerance).
• Putting client’s behavior under control of delayed consequences.
• Increase the verbal descriptions of feelings and the relationship with occurring
CRs (self-knowledge, specifically on anxiety).
184 A. S. Aranha et al.

Procedures

1. Metaphors (extended tact) as antecedent stimuli to increase the control of analo-

gous conditions over the client’s repertoire. The metaphors were used to mitigate
the aversive function of the intervention and decrease the chance of
countercontrol.
Example:
T: You arrive at work and your boss has moved your chair. He knows you liked
where the chair was. You go talk to him and he says, “You’re fired, get away.”
C: I get your point.
T: She complained about the disappearance. You said you wouldn’t live together
anymore.
C: Out of proportion.
The psychotherapist handled hypothetical situations where a third party knew the
client’s preferences, behaviors and feelings, and behaved without taking them into
account. Specifically in the example described, the goal was to make the client more
sensitive to his girlfriend. Mélvio had been drinking, using drugs, and arriving home
late. When Raissa started a conflict, he responded that he “would no longer live
together”. The intervention consisted of making the client aware of his impact on
his girlfriend saying “he was leaving” and the inadequacy of his behavior (the
behavior of using drugs, arriving late, and being frustrated are worthy of criticism).
Accepting he was emitting unwanted behaviors helped to attack the distorted self-­
esteem (“I’m not good at what I do, I have behaviors that don’t make me everything
I thought I was”).
2. Description of the concept of three-term contingency of reinforcement and the
anxiety model of Estes and Skinner (1941).
Example:
T: [therapist explains the components of the triple contingency and the anxiety
model of Behavior Analysis].
C: I’m trying to find the red light of my life.
The description of the concept of three-term contingency (in several sessions and
using client examples) reaches two important issues of Mélvio: the deficit in getting
under control and analyze the CRs that affect the behavior of others, and the deficit
in analyzing the behavior itself and the variables of which it is a function. The basic
unit of Behavior Analysis promotes the knowledge that our behaviors and people
are controlled by CRs and are not free choices. Mélvio should learn that the other
had reasons to please or annoy him, to do what he wanted or not to do. On the other
hand, the client had a certain behavioral pattern because of his HCR and the occur-
ring CRs and not because using drugs, being impulsive, irresponsible, selfish, and
arrogant was his decision.
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 185

The concept of contingency of three terms facilitated the explanation of the anxi-
ety paradigm, making it easier for Mélvio to understand that “panic attacks” had
historical and environmental determinants.
3. Use of timeline with possible SD function to evoke identification responses of
the components of the controlling variables.
The psychotherapist separated all the notes on the anxiety reports, as well as the
previous sessions in which the client claimed to have used alcohol and cocaine. He
then drew a timeline on a paper sheet, marking the dates of each abuse episode and
each reported crisis, aiming to increase the establishment of the consumption-­
anxiety relationship and to install avoidance behaviors of anxiety crises under con-
trol of specific events (discriminating that drug use would cause anxiety and
avoiding by not using, drinking less, leaving the bar, etc.). Considering Mélvio’s
impulsive behavior, the original notes were always at the client’s disposal for him to
compare events and dates (the notes, as verbal stimuli, were present in the environ-
ment). It was also expected that, if the intervention was successful, it would increase
the chances of generalization and Mélvio would respond under control of other
delayed consequences.
4. Description of possible consequences of client response on people.
Example:
T: Sounds like a compensation Scheme. I’m good, I deserve to have fun. You didn’t
find me good-looking, you didn’t compliment me, I deserve to make fun. He
didn’t reply, I deserve to get angry. It’s a prize.
C: [Crying] That’s it. That’s me. How embarrassing! My family will stop loving me.
T: Maybe they won’t stop loving you, but they might get tired of worrying. Neglect
is like disaffection.
The psychotherapist described the possible responses with aversive phenotype
emitted when Mélvio was deprived and frustrated, and the effect of these responses
on the client’s family, friends and partners. People could feel bad, change their con-
cepts about Mélvio and change the relationship that existed between them.
5. Progressive presentation of consequent stimuli with possible mild aversive func-
tion to the self-valorization verbalizations related to drug abuse.
Example:
[Whatsapp dialog]
C: That’s very crazy! I got cocaine in [name of the country].
C: I used it here. I did it. That’s pretty crazy.
T: Are your activities over? [changes subject].
C: No.
C: I mean, more or less. There are the guys from [the work] who are going to present
[the slides of a project] and I theoretically just have to watch.
T: [Pause] Theoretically?
186 A. S. Aranha et al.

C: Because their work depended on mine and I may have to explain something.
C: But look how crazy. I did all this in another country and I wasn’t afraid at
the time.
C: I used coke in [name of country].
T: Actually, Mélvio, the place is of little importance. Whether it was in Europe or in
a drug den. we have to understand the function of that at the moment. My con-
cern is that this will become another cool story to be told to close friends.
C: It won’t.
C: It can’t.
According to Guilhardi (2010b), before employing any punitive procedure, care-
ful evaluation and failed attempts at positive reinforcement interventions are
required. On behalf of the client’s HCR, the simple reporting of situations that pro-
duced any kind of attention by the verbal community was itself conditioned rein-
forcement, even if it produced unpleasant bodily sensations. It was important for the
client to be under the control of the CRs that made him or her vulnerable to the
effects of drugs and not just the effects. The psychotherapist, throughout the dia-
logue exemplified above, tried to draw attention away from the exaltation part of the
report, taking time to respond or changing the subject, but without success. Since
the client continued to select and repeat the part where he boasted about the behav-
ior, the psychotherapist overlooked the verbalization about using drugs in different
places (“a cool story to be told”).
The intervention was also intended to gradually increase Mélvio’s frustration
tolerance. The psychotherapist, different from the agents that only presented rein-
forcers or aversive stimuli, turned into an audience that, in part, maintained a pleas-
ant relationship, but did not agree with all of the client’s statements. Mélvio should
tolerate an interaction in which, although reinforcing, he would not be valued for
anything he said.

Results

1. Awareness of occurring CRs and effective escape behaviors in contexts that

evoked substance consumption.
Example:
C: Crap night.
In a given situation, upon arriving at a party and identifying that people were
using drugs, he reported that it was a “crap night” and that it would probably be a
precedent to use, which would cause poor performance at the next day’s work meet-
ing (delayed punishment). He left the place. In addition, Mélvio began to anticipate
social events that would involve drinking alcohol, taking non-alcoholic beer for his
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 187

own consumption and learning to make soft drinks, despite jokes about his “mascu-
linity” for not drinking alcohol.
Mélvio reported differentiating “friends of the night” and friends more sensitive
to his problems. He said he had changed the way he saw them, because what seemed
critical before was seen as care and that he began to admire qualities he found “bor-
ing” in such people.
2. Decrease in the frequency of behaviors under control of immediate
consequences.
Example:
C: I finally received [the payment three weeks late].
T: What’s up?
C: I thanked like a gentleman. I didn’t even make a scene. It was their mistake, but
okay. I don’t like not getting paid, but I’m not gonna get misjudged.
Some impulsive behaviors decreased in frequency and Mélvio reported thinking
more before speaking. He mentioned a situation where the salary was delayed due
to a human resources error and for two weeks he mentioned in session how much
more days had been delayed and the problem had not been solved. In the third week
he said that the salary had been paid and that he did not make the “fight” that he
would do in other situations.
Mélvio also looked for an accountant to survey his debts and help him with
financial planning.
The frequency of substance use has also dropped. According to Mélvio, he still
“allowed” himself to use on his birthday (once a year).
3. The client has resumed past activities that produced alternative reinforcers to the
substances of abuse.
Example:
C: I went to the gym, I liked the place. I thought there would be only professional
athletes [laughs]. I already signed up.
Along with the above results, psychotherapist and client began to look for activi-
ties that once had considerable reinforcing value for the client. Mélvio returned to
the practice of sports and composing music by computer.
4. Emission of behaviors with milder phenotype (“assertive”).
Example:
C: Don’t talk to me like that Raissa, tell me you’re worried, plan something with me,
otherwise I’ll get angry and want to get drugs. I’m not just “someone who
uses drugs”.
Mélvio started to emit less aversive behaviors in several contexts. In relation to
the family, which he referred to as “a group of people who put everything ‘under the
188 A. S. Aranha et al.

carpet’” and from whom he replicated models of “inassertive” behaviors in interac-

tions, the client started to pull conversations and talk about himself, including his
difficulty in relation to drinking and drugs and about past events that had adverse
consequences for him and his family members.
In relation to Raíssa, the client started to behave, especially in situations of con-
flict, in a more polite way instead of fighting, indicating to the psychotherapist (in
the example) a situation where he was going to spend a few days away and that his
girlfriend had said “she would be insecure because he was a junkie” and that “the
next time he used drugs he would die”.
5. Identification that the crises were emotional episodes related to possible aversive
consequences of drug use.
Example:
C: At least I know I won’t die. I already know why I’m like this. I feel bad. I feel that
my body is bad, but I can understand that I’m not really going to die. That this is
pure anxiety.
T: Today you know yourself better.
C: Yeah. It’s hard, but I know I’m not gonna die.
Mélvio came under the control of the CRs that produced fear and anxiety, that is,
the antecedents that signals that the consumption of SPA would follow the loss of
financial, social and pharmacological reinforcers in the future. With this, the cata-
strophic and spurious interpretations for what I felt diminished. He began to ques-
tion the relevance of reinforcers in his life.

Final Considerations

TCR is a psychotherapeutic proposal based on BS (Skinner, 1953) and RB (Skinner,

1945) that argues that substance dependence be interpreted as a set of respondent
and operant behaviors (e.g., withdrawal syndrome, tolerance, obtaining drug, drug
consumption) that should be therapeutically altered by changing the CRs that install
and maintain such classes of behavior. Additionally, it requires an analysis and
intervention in other more comprehensive behavioral classes (excesses and deficits)
that contribute to the installation and maintenance of PAS consumption behaviors,
such as low self-esteem, low self-knowledge, low self-confidence, low frustration
tolerance, impulsiveness, recklessness, deficits of discipline and healthy activities
and excessive dependence on social approval, more easily achieved by bizarre and
risky behaviors and excessive sensoriality, as exemplified in the case presented. It
also analyzes behaviors that may be unrelated to PAS. The phenotypic similarities
of users’ behaviors hide that, essentially, each person is different in multiple aspects
in their reasons for abusive use and in the multiple repertories that make up their
12 Therapy by Contingencies of Reinforcement (TCR) and Substance Dependence… 189

being, which extend far beyond the behavioral classes directly linked to the drug
and which need to be changed concomitantly. As such, each individual needs indi-
vidualized psychotherapeutic treatments, which, guided by general behavioral prin-
ciples and laws, are presented in interactions with the chemical dependent as
individual techniques, adjusted to individual needs (along with submitting to stan-
dard procedures, basically those guided by medicine). Two people are not exactly
the same; two treatments are not exactly the same. CR presents such a proposal and
is prepared to assume it in psychotherapeutic processes conducted with substance
dependents.

Acknowledgments To the psychologists Hélio José Guilhardi and Lylian Cristina Pilz Penteado
in the construction of this chapter.

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Chapter 13
Motivational Interviewing Under
a Behavior Analysis Perspective

César Silva Rodrigues Oliveira and Edson Massayuki Huziwara

Introduction

Motivational interviewing (MI) is a treatment method used in the field of substance

use disorders (SUD), developed by William R. Miller from his own clinical
experience. MI is largely based on the person-centered approach (Rogers, 1959), as
well as on other theories of social psychology and, although its origin is related to
the area of substance abuse and dependence, this method has been widely studied
and used for several other behavioral domains, such as adherence to the practice of
physical exercise, modification of eating habits, and reduction of risky sexual
behavior, among others (Lundahl et al., 2010). In addition, it has been shown to be
more effective than no treatment and similarly effective than other treatment options,
although more cost-effective due to its brief intervention character (Lundahl &
Burke, 2009; Smedslund et al., 2011).
The objective of this chapter is to introduce MI to the behavior analysts’ com-
munity, especially those unfamiliar with methods for treating patients with SUD, as
well as to provide an analytical-behavioral understanding of the method and its
main strategies.

Motivational Interviewing: Its Origins

According to Miller, in a report presented in the third edition of the book enti-
tled Motivational Interviewing (Miller & Rollnick, 2013), in the 1980s, the
addiction treatment in the United States was often highly authoritarian,

C. S. R. Oliveira () · E. M. Huziwara

Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 193
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_13
194 C. S. R. Oliveira and E. M. Huziwara

confrontational, humiliating, and relying on a directing style of counseling.

People with such problems were characterized as pathological liars, with imma-
ture personality defense mechanisms and also with problems to maintain con-
tact with reality. Surprisingly, Miller’s first experiences in treating people with
alcohol problems revealed that they were often open, interesting, and aware of
the problems produced by their behavior. It did not take long for him to realize
that the openness or resistance of the patient appeared to be a product of the
established therapeutic relationship rather than a personality trait of individuals
with such problems.
In a clinical trial of behavioral therapy for alcohol-related problems (Miller
et al., 1980), the authors trained nine counselors in self-control techniques and
in person-­ centered approach skills such as accurate empathy. After being
trained, the same counselors performed self-control training in outpatients.
Three supervisors observed and rated the extent to which each counselor exhib-
ited accurate empathy while conducting the training. The therapist’s empathy
was able to predict two-­thirds of the variance in the patient’s alcohol consump-
tion six months after treatment ended. Thus, the results observed suggested the
importance of the therapist’s emphatic style to engage patients in the proposed
treatment.
After these initial findings (Miller et al., 1980), Miller developed the first
version of his treatment approach. In a trip to Norway, the author had the oppor-
tunity to present and discuss the theoretical and empirical basis of this new
approach with a group of psychologists gathered at the Hjellestad Clinic (Miller
& Rollnick, 2001). According to Miller and Rose (2009), this environment was
important for the clarification of his method, besides it has been an event that
helped him in an important way in the writing of his original article, published
in 1983 (Miller, 1983). In 1989, on a trip to Australia, Miller met Stephen
Rollnick, who reported that MI was very popular in the treatment of SUD in the
UK. Rollnick encouraged Miller to write a book,1 which he co-authored, sys-
tematizing and helping to spread knowledge about MI. Since then, much has
been produced and modifications have been proposed in relation to the concepts
presented in the first edition of the book, such as the inclusion of the notion of
the “spirit” of MI in the second edition,2 in addition to an emphasis on the con-
cept of change talk and sustain talk gathered in the third edition3 together with
an update of the “spirit” of MI.

1
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: preparing people to change
addictive behavior. New York: The Guilford Press.
2
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people for change
(2nd ed.). New York: The Guilford Press.
3
Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing: helping people change (3rd ed.).
New York: The Guilford Press.
13 Motivational Interviewing Under a Behavior Analysis Perspective 195

Motivational Interviewing: Definition and Strategies

A basic element of MI refers to the understanding of ambivalence as a common and

present behavior in any process of change. That is, having reasons to change and, at
the same time, not to change is a normal human experience. According to Miller and
Rollnick (2013), when a person presents ambivalence in relation to a subject of
interest it is common to alternate the emission of two types of speech during a
conversation. One type would be the change talk, in which the patient argues for
change giving reasons, talking about his or her ability to change or committing to
change. Another type would be the sustain talk, which corresponds to arguments in
favor of maintaining the current behavior. According to the assumptions of MI, the
therapist arguing in favor of change is counterproductive, since it causes sustain talk
by the patient, which generally reinforces the conception that people with SUD are
resistant, opposed, and in constant denial of their problems. In this scenario, one of
the main objectives of MI is to modify risk behavior by exploring and solving this
ambivalence. Thus, MI is defined as “a client-centered, directive method for
enhancing intrinsic motivation to change by exploring and resolving ambivalence”
(Miller & Rollnick, 2002, p. 25).
In a more recent definition, the same authors refer to MI as:
(…) a collaborative, goal-oriented style of communication with particular attention to the
language of change. It is designed to strengthen personal motivation for and commitment
to a specific goal by eliciting and exploring the person’s own reasons for change within an
atmosphere of acceptance and compassion. (Miller & Rollnick, 2013, p. 40).

At least two notions are important for the characterization of the MI, namely its
“spirit” and processes. According to Miller and Rollnick (2013), there is an attitude
that must be maintained by the therapist throughout the process, which the authors
call “spirit”. In the authors’ own words, “without this underlying spirit, MI becomes
a cynical trick, a way of trying to manipulate people into doing what they don’t want
to do” (Miller & Rollnick, 2013, p. 23).
There are four elements that make up the “spirit” of MI: partnership, accep-
tance, evocation, and compassion. Partnership involves establishing a positive
interpersonal atmosphere that is conducive to change, but not coercive. The thera-
pist searches for establishing an active collaboration between experts, considering
that the patients are undisputed experts on themselves, to value the patient’s per-
spectives, avoiding imposing the therapist’s vision on the patient’s vision. The
deep acceptance derives from four other elements extracted from Carl Rogers’
work, namely, absolute worth, accurate empathy, support to autonomy, and affir-
mation. In short, acceptance would involve recognizing the inherent value and
potential of each human being; developing an active interest and effort in under-
standing the perspective of the other in his/her own way; honoring and respecting
the autonomy or the irrevocable right of the person to choose his/her own path;
and highlighting the strengths and efforts of the person, rather than what he/she
lacks. In turn, evocation refers to the therapist strengthening the motivations for
196 C. S. R. Oliveira and E. M. Huziwara

change that are already present rather than focusing on installing that which is
absent. Finally, compassion is about promoting the well-being of the other and
prioritizing the needs of the other in the relationship.
Besides the “spirit” of the MI, another important notion for its understanding
concerns its processes. In the first two editions of the book “Motivational
Interviewing”, the authors described MI operating in two phases: “building
motivation” and “consolidating commitment”. This division suggested a linear
process of change, which did not correspond with the clinical observations. The
process of MI, on the contrary, seems to be a process of phases, in which one
overlaps with the other. These processes are thus recursive and, at the same time,
sequential. Thus, in the third edition of the book, the authors elaborated four
processes, which were expressed in the gerund to better represent its sequence and
overlapping: “engaging”, “focusing”, “evoking”, and “planning”. “Engaging”
consists in the process of building a therapeutic alliance that searches for solutions
to the problems encountered. “Focusing” is the process by which a specific direction
is developed and maintained in the conversation about change. “Evoking” is about
evoking the patient’s own motivations for change, i.e., having the patient himself
argue for change. Finally, “planning” encompasses both the development of a
commitment to change and the formulation of an action plan.
The practice of MI involves the flexible use of communication skills appropriate
to the person-centered approach. These skills are present throughout all the processes
of MI and are summarized under the acronym OARS,4 formed from the expressions
(1) open questions; (2) affirming; (3) reflections; (4) summarizing. Open questions
are invitations to think and elaborate, unlike closed-ended questions, which search
for specific information and can be answered by a short answer. In “engaging” and
“focusing” processes, they help the therapist to understand the patient’s frame of
reference, strengthening a collaborative relationship and finding a direction, while
in “evoking” and “planning” they help to strengthen motivation and to develop a
plan for change. Affirming, on the other hand, is both general and specific, that is, it
concerns both the therapist’s ability to be attentive to the patient’s resources and
qualities and also to value his or her abilities, good intentions, or efforts during the
sessions. Reflections are very important skills, since they clarify and deepen the
meaning of what is said by the patient, as well as keeping him talking and exploring
issues related to the desired behavioral change. They can be simple (i.e., literal
reproductions of what the patient said) or complex (i.e., reproductions of the sense
of his speech). Moreover, in MI, reflections are necessarily selective, which means
that the therapist objectively selects what to reflect on, especially in “evoking” and
“planning” processes, directing the patient’s attention to specific aspects of his
speech. Summarizing, in turn, constitutes wider reflections that connect current
information with past information, besides being important in moments of transition
from one task to another. In “engaging” and “focusing”, the abstracts make it clear

4
Originally, in English, the acronym is OARS, formed by open questions, affirming, reflections and
summarizing.
13 Motivational Interviewing Under a Behavior Analysis Perspective 197

to the patient that the therapist was attentive to what was said, valuing the content of
the speech. In “evoking” they have the role of bringing together the change talk to
continue the process of change, while in “planning” the summaries help to gather
specific motivations, intentions, and plans for change.
In addition to the acronym, there is also a fifth skill which is “informing and
advising”. There are times when it is important to provide the patient with advice or
information; however, they do not occur without the patient’s consent to receive
them and the therapist should make an effort to verify that the information is being
well understood, according to the patient’s ability to assimilate it. Furthermore, it is
important for the therapist to remember that it is his job to allow patients to reach
their own conclusions with the information or advice received.
Finally, Miller and Rollnick (2013) suggested that for a therapist to get the full
learning from MI, it is important to have mastery of 12 tasks: (1) understand the
underlying spirit with which MI is practiced, namely, partnership, acceptance,
compassion, and evocation; (2) develop skills and comfort with reflective listening
and OARS skills; (3) identify change goals to move toward; (4) exchange information
and provide advice within an MI style; (5) be able to recognize change talk and
sustain talk; (6) evoke change talk; (7) respond to change talk in a way that
strengthens it; (8) respond to sustain talk in a way that does not amplify it; (9)
develop hope and confidence; (10) learn the right time to negotiate a change plan;
(11) strengthen commitment; and (12) integrate MI flexibly with other clinical skills
and practices.

Motivational Interviewing: Mechanisms of Change

For MI, the change in behavior, in addition to a relational component based on its
“spirit”, which is responsible for reducing patient resistance, also depends on the
appropriate use of techniques, which will allow the increase of change talk and
decrease of sustain talk (Lundahl et al., 2011; Miller & Rose, 2009). Amrhein,
Miller, Yahne, Palmer, and Fulcher (2003) found that a higher number of statements
of commitment to change during the session predicted an increase in the proportion
of abstinent days in drug abusers. Moyers and Martin (2006) further noted that
therapists with speech consistent with the spirit of MI evoked more change talk,
while those with inconsistent speech evoked more sustain talk.
Magill et al. (2014) performed a meta-analysis of the causal model established
by MI seeking to evaluate the hypothesis that MI strategies produce changes in the
discourse of patients and that these changes predict treatment outcomes related to
behavior change. The found results confirmed that: (1) therapeutic skills consis-
tent with MI (e.g., open-ended questions, reflections, and affirming) were associ-
ated with higher rates of change talk, while therapeutic skills inconsistent with MI
(e.g., confrontations, warnings, unsolicited counseling) were associated with
fewer change talk and more sustain talk; (2) higher rates of sustain talk were asso-
ciated with worse treatment outcomes; (3) combined measures of change talk and
198 C. S. R. Oliveira and E. M. Huziwara

sustain talk, as well as statements of commitment, were positively related to

behavior change, although change talk when taken alone was not associated
with change.

 otivational Interviewing and Behavior Analysis:

M
An Approach According to Christopher and Dougher (2009)

Both Behavior Analysis and MI assume the relational nature of motivation for
change. For Behavior Analysis, any behavior, including verbal one, is a function of
the environmental variables that control its occurrence (Skinner, 1957, 1981). In
this sense, a way to reinforce a given verbal behavior would involve the planning of
adequate contingencies for the occurrence of such behavior. MI can be understood
as a method in which there is a conscious effort by the therapist to come under
control of the occurrence of so-called change talk, establishing the occasion for its
emission and reinforcing its occurrence. In other words, through the person-centered
approach (OARS) communication skills, there is an effort to differentially reinforce
the occurrence of change talk within an environment with minimal aversive control
(Christopher & Dougher, 2009).
A therapeutic environment with minimum levels of aversive control necessarily
requires that the therapist constitutes a non-punitive audience (Skinner, 1953) for
the patient. SUD patients usually come to clinical setting brought by family members
and have a long history of exposure to coercive strategies to control their behavior
which makes a non-punitive posture extremely necessary. Otherwise, an increase in
the frequency of speech that topographically resembles change talk (e.g., perceptions
of many losses related to the drug use) may be under control of reinforcers other
than a real process of change (e.g., avoiding a reprimand by the therapist) (Oliveira,
2007). In other words, the change in the patient’s verbal behavior may not be related
to a change in the target behavior if coercive strategies are being employed, since
such strategies may reinforce the occurrence of responses that reduce the probability
of punishment, that is, characteristic responses of countercontrol strategies
(Delprato, 2002).
The therapist’s attention to the sequential, recursive, and overlapping nature of
the four processes proposed by MI (i.e., “engaging,” “focusing,” “evoking,”
“planning”) probably helps to reduce the occurrence of countercontrol responses. In
other words, the differential reinforcement of change talk (i.e., a task proper to the
“evoking” process) should not occur without the therapist first establishing a
relationship of trust with the patient, establishing himself as a non-punitive audience
(i.e., “engaging” task) and differentiating himself from the others who previously
punished him. In other words, tasks related to the “engaging” process should occur
before tasks related to the “evoking” process. At the same time, a therapist can use
strategies of the “engaging” process even when “evoking” process tasks are being
performed, which confers the circular character of these processes.
13 Motivational Interviewing Under a Behavior Analysis Perspective 199

In summary, the therapist is more likely to establish himself as a non-punitive

audience behaving in accordance with the “spirit” of MI (i.e., establishing a
partnership relationship, not authoritarian, in which he values the knowledge of the
patient about himself, not reprimanding or judging his behavior, and strengthening
his motivations instead of implanting others), which helps to evoke more precise
tact regarding the contingencies that govern his behavior. The more precise the
patient is to contact the reinforcers or aversive stimuli associated with his or her risk
behavior, the more accurate the patient’s functional analysis can be described
(Christopher & Dougher, 2009).
For example, an initial statement from an SUD patient may indicate that he
would like to know strategies for stopping drug use. Moreover, other statements
may also suggest that he does not understand the reasons for maintaining this
behavioral pattern or cannot point out positive aspects related to drug use. A more
detailed analysis, however, may reveal that tacts regarding the reinforcing
consequences of drug use have been punished in the past, which is why the patient
would have omitted them at this point.
Additionally, this behavioral pattern at the beginning of a therapeutic relation-
ship possibly also indicates aversive consequences related to being judged by others
in daily life. The therapist could even use this situation to explore other behaviors
that fulfill the same function (e.g., isolate himself from people who do not use drugs
to not be judged) and the distal consequences related to them. In general, faced with
a demand as described in the previous example, therapists could focus only on
implementing training in self-control strategies, missing the opportunity to expand
the patient’s contact with the problems related to the use of the substance (e.g.,
isolation of non-users) as well as to address the reinforcing consequences of this
behavior (e.g., drug use euphoria, drug users socialization, escape from the
responsibilities of daily life). Such a strategy could be an opportunity to recognize
the need to expand contact with other reinforcers or to address alternative behaviors
to produce similar reinforcers. In this sense, the use of simple open-ended questions,
as proposed by MI (e.g., “what do you like about your cocaine use?” and “and what
don’t you like?”), can establish the occasion for a more in-depth analysis of the
conflicting consequences and contingencies competing with the use of the substance.
A more precise tact of the patient on the exemplified situation could be something
like this: “I like the acceleration that cocaine causes me. I talk a lot, I get along
easily with the guys, especially after a stressful week that I spend with the care of
my son, dedication to work and home. At the same time, I realize that I have become
increasingly isolated from my family and friends. I am very embarrassed to face
them, especially after nights that I come sniffing around. My son, as he is still very
small, does not understand, but he will soon understand” (sic). That is, by behaving
in accordance with the “spirit” of MI and through the use of OARS communication
skills (i.e., open-ended questions, affirming, reflections, and summarizing), the
therapist indicates the absence of punishment and establishes himself as a
discriminative stimulus for the patient to speak freely about their problem,
reinforcing tacts from every contingencies related to the target behavior (Christopher
& Dougher, 2009).
200 C. S. R. Oliveira and E. M. Huziwara

According to Christopher and Dougher (2009), among OARS communication

skills, reflections (i.e., literal reproductions of the patient’s speech or meaning)
are critical to understand how the method can increase the frequency of change
talk. In addition to the fact that the reflections have an autoclitic function,5 since
they increase the effect of the therapist’s verbalizations that intend to communi-
cate acceptance, they can function as establishing operations,6 since they increase
the reinforcing properties of the therapist’s verbal behavior, thus leading to an
increase in the likelihood of the patient emitting previously punished, painful, or
sensitive behavior about his problem. In the example mentioned above, a reflec-
tion said by the therapist could be something like this: “you notice that you have
become more and more isolated from your family and friends because you feel
ashamed. Also, you worry about your child’s reaction when he or she can under-
stand what is going on with you”. In the face of this intervention, it would be
likely that the patient would agree with the therapist and continue talking about
this relevant clinical issue. Additionally, the patient would be more likely to “react
better” to the therapist’s future verbalizations. In this way, acceptance, signaled
by reflection, can evoke a more precise exploration of the previously avoided
contingencies, which can decrease the number of imprecise tacts about the contin-
gencies related to the maintenance of the behavior problem (Christopher &
Dougher, 2009).
For a more accurate understanding of how MI increases the change talk,
Christopher and Dougher (2009) also sought to functionally define the different
types of reflection and their different functions. In general, all of them could be
classified as mands, since such reflections are operant behavior maintained by the
specific consequence of evoking change talk and diminishing characteristic
countercontrol responses, although they can also have an intraverbal function
because they are evoked by a verbal discriminative stimulus. Simple reflections, for
example, are those in which the therapist merely what repeat some patient’s
sentences, demonstrating that he understands what the patient said.
Complex reflections are related to a deeper level of demonstration of under-
standing in which the therapist specifies the contingency that controls the verbal-
ization of the patient. Suppose, for example, that the phrase “I like the acceleration
of cocaine” is said by the patient after the therapist has encouraged him to abstain
from cocaine. In this context, the patient’s phrase may be understood as a coun-
tercontrol response to avoid the therapist’s punishment, who signaled his expecta-
tions regarding behavior change. The therapist could respond as follows: “I
understand … it would be difficult for you to stop using”. In this sense, complex
reflection can help reduce countercontrol, while increasing the likelihood that the

5
The so-called autoclitic operant consists of a verbal unit that occurs together with other basic
operants, modifying the effects of these basic operants on the listener (Barros, 2003; Borloti, 2004;
Skinner, 1957).
6
Establishing operations are environmental events that momentarily change the effectiveness of a
stimulus as a reinforcer or punisher. This concept, in behavioral terms, is related to what is called
motivation in generic terms (Michael, 1993; Miguel, 2000).
13 Motivational Interviewing Under a Behavior Analysis Perspective 201

patient will talk about the contingencies that control his abilities to change
(Christopher & Dougher, 2009). An amplified reflection is a speech in which the
therapist usually exaggerates the patient’s sustain talk for reducing countercon-
trol. At the same time, this type of reflection increases the probability that the
patient will engage in more exploratory behavior for specifying the contingencies
that control the problematic behavior. For example, in the face of a phrase like
this: “using drugs helps me relax,” the therapist may respond: “using drugs is the
only way you relax”. In this context, the patient is asked to agree with the speech
that restricted the class of relaxing events to cocaine use or to repair it, describing
other behaviors that share the same relaxing function. Thus, cocaine use becomes
one more among other behaviors of this functional class that can still be distin-
guished as generating delayed aversive consequences (Christopher &
Dougher, 2009).
Another speech by the therapist, named double reflections, relates the change
talk with the sustain talk through a connective word such as “and”, making clear the
divergence between the patient’s values and his or her current behavior. For instance,
the therapist may say a phrase such as: “you worry about being away from your
family and find it difficult to relax without cocaine”. Christopher and Dougher
(2009) point out that in this case, the therapist’s reinforcement by the patient having
verbally come into contact with these contingencies can, through empathetic
reflection, increase the reinforcing value of talking about behavior change,
functioning as an establishing operation for the emission of change talk like that:
“maybe I can learn new ways to relax without cocaine”.
Finally, the summaries, as more extensive reflections, relate the change talk and
the sustain talk, trying to describe the full extent of contingencies that compete in
controlling behavior. According to the authors, patients would be more inclined to
express a commitment to change considering that they have already explored other
behaviors that share the same function of the problem behavior without producing
aversive consequences and come into contact with the discrepancy between their
values and their current behaviors. In these conditions, the therapist reinforces the
elaboration of selfmands about the change and helps the patient to elaborate a
plan for it.
For the constitution of this plan, MI makes clear the importance of providing the
patient with advice or information as long as the therapist has permission or consent
to do so. Asking permission to inform or advise is a type of verbalization that
performs an autoclitic function over other mands of the therapist, since they alter the
aversiveness of the information or advice given, which may increase its effectiveness.
To illustrate, a good example could be: “Would it be ok for you if I told you some
strategies that other people use to stop using cocaine?”
Having explained how empathetic reflections can set the context for reinforcing
change talk, Christopher and Dougher (2009) suggest the following functional
definition of MI, which is reproduced here:
(…)MI evokes change talk by creating a therapeutic relationship of acceptance, collabora-
tion, and client autonomy, which reduces counterpliance and avoidance of contact with
painful contingencies related to drinking, while deliberately and differentially reinforcing
202 C. S. R. Oliveira and E. M. Huziwara

change talk by using client-centered counseling skills (OARS) to establish variation in cli-
ent verbal behavior related to change. The therapist reinforces the client’s behavior of
accurately tacting the full range of competing contingencies, both historical and current
and proximal and distal, that govern drinking behavior. Thus, MI is essentially an environ-
ment deliberately arranged for the evocation of change talk and the elaboration of self-
mands that are correlated with behavior change. (Christopher & Dougher, 2009, p. 155).

Christopher and Dougher (2009) therefore highlight the importance of OARS

communication skills and the “spirit” of MI in shaping a non-punitive audience
environment, which reduces countercontrol responses. The authors also empha-
size the importance of differential reinforcement of tacts on the various aversive
and reinforcing consequences of risk behavior to collaborate in the elaboration of
selfmands related to the desired behavior change. Although several studies high-
light the correlations between change talks and behavioral change (Amrhein
et al., 2003; Magill et al., 2014), the functional relationships between these two
factors have not yet been clearly explored, as the authors highlight. In other
words, why does increasing change talk influence post-session behavior?
According to these same authors, three processes related to rule-based behavior
(Skinner, 1969) would explain such influence. In the first case, the social contin-
gencies present during the session and in the patient’s natural environment rein-
force the statement of commitment to change, which is a function of the
interpersonal contingencies of the session in addition to the description of past
and future consequences of the target behavior. This social environment, there-
fore, begins to monitor and reinforce behaviors congruent with the commitment
made. Another process is related to the weakening of the control of certain rules,
either when amplifying a class of behaviors that produce relaxation, weakening
the rule “cocaine helps me relax”, or clarifying behaviors necessary to deal with
conflicting contingencies, weakening the rule “my life will be better if I stop
using, but I can’t”. Finally, the process in which the therapist searches for evok-
ing and understanding the patient’s values is highlighted, thus expanding contact
with high-magnitude reinforcers, which can help maintain certain behaviors even
in the face of the availability of more immediate reinforcers in competing
contingencies.
Using a more recent interpretation that presents considerable differences in the
interpretation of verbal behavior when compared to Skinner (1957), Christopher
and Dougher (2009) still highlight that the literature on function transformation
(Hayes et al., 2001) is necessary for the explanation of why the verbal behavior of
the patient and the therapist may alter the behavioral patterns emitted in the post-­
session. As Wilson and Hayes (2000) have pointed out, MI can figure as a poten-
tially effective clinical strategy to alter the stimulus function of the ultimate
consequences of a substance use contingency. However, it is beyond the scope of
this chapter to present concepts related to RFT (Relational Frame Theory), although
it is recognized the importance of understanding the effects of verbal contingencies
involved in the relational response of substance users.
13 Motivational Interviewing Under a Behavior Analysis Perspective 203

Final Considerations

According to the presentation, the manipulation of verbal behavior in the therapeu-

tic environment, to some extent, may favor the change of risk behaviors displayed
outside the aforementioned setting. Despite the differences between the theoretical
bases of MI and Behavior Analysis, the propositions made by this method were
analyzed in behavior analytic terms by Christopher and Dougher (2009), helping
behavior analysts to assimilate effective clinical strategies for the treatment of
SUD people.
For both MI theorists and behavior analysts, there is a special interest in under-
standing how verbal contingencies can participate in behavioral control. Although
Christopher and Dougher (2009) have shed light on the likely mechanisms respon-
sible for verbal behavior during MI sessions to change the source of target behavior
control, further studies are needed to clarify these issues.

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BF03391997
 Part III
Special Topics
Chapter 14
Interfaces Between Neurosciences
and Behavior Analysis on the Use
of Psychoactive Substances

Myenne Mieko Ayres Tsutsumi, André Luiz, Carlos Eduardo Costa,

and Célio Roberto Estanislau

Introduction

Understanding the variables that influence substance use and abuse behavior is a
task of enormous importance. This task becomes even more complex when it is
necessary to present possible relationships between two fields of study, in this case
Behavior Analysis and the Neurosciences.
First, there is the need to present some concepts from both areas to then outline
possible interfaces between them. Before that, it is important to state that the present
chapter arose from dialogues between the authors on the subject, which was the best
way found to trace relationships between the areas of study, without the bureaucracy
of roles playing a control, sometimes unnecessary, in the development of the ideas
here present. Thus, the reader is advised not to take the present text as a rule of rea-
soning to trace relationships between different fields of study. Constructing inter-
faces is the result of a wide history of conversations which, when translated into
written words, seem to occur in a linear manner. It is therefore indispensable to meet
people from different areas, discuss, contest, and complement what is written here.

M. M. A. Tsutsumi ()
Pontifícia Universidade Católica do Paraná (PUC-PR), Londrina, PR, Brazil
Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil
A. Luiz
Universidade Positivo – Faculdade Londrina, Londrina, PR, Brazil
Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil
Núcleo Evoluir, Londrina, PR, Brazil
C. E. Costa · C. R. Estanislau
Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 207
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_14
208 M. M. A. Tsutsumi et al.

Behavior Analysis

Behavior Analysis is a science based on the philosophical principles of Radical

Behaviorism (Chiesa, 2006). In the preface of the book Subjectivity and Behavioral
Relations (original tittle: Subjetividade e Relações Comportamentais), written by
Tourinho (2009), the psychologist Roberto Banaco defines radical behaviorist phi-
losophy as enchanting and frightening. The enchantment comes from the intensive
use of the principle of parsimony, in which one tries to explain natural phenomena
in the simplest way possible. Radical Behaviorism would therefore be charmingly
simple. The frightening characteristic, in turn, is formed by embracing an explana-
tory model that is very different from common sense, taking the absolute control of
their lives out of the hands of human beings and shedding light on their submission
to the Laws of Nature. In other words, it would be frighteningly different from the
most common conceptions of freedom.
To say that the human being is under the Laws of Nature should not cause aston-
ishment or strangeness. Organisms are part of the natural world, so are their behav-
iors. That means, ultimately, that behavior is determined. In this sense, behavior is
an event that does not occur at random, but as a result of a set of relationships among
other events in the past (Marçal, 2010). Therefore, behavior is the result of a histori-
cal process.
“Behavior” does not just refer to what can be directly observed (e.g., kicking a
ball). Thoughts, feelings, ideas, emotions, choices, intentions, etc., are also consid-
ered behaviors and are therefore the result of a historical process. Here it is possible
to perceive the Monistic and Materialistic vision of Radical Behaviorism: there is
no distinction between physical and metaphysical in organisms (Chiesa, 2006).
Public behaviors (those that can be observed directly) and private behaviors (those
that are accessed directly only by the individual himself) occur in the same natural
dimension and are subject to the same natural laws (Skinner, 2006).
To refer to private behaviors, Skinner (2006) used the definition “the world under
the skin” and said it would be foolish to neglect what occurs in that world because
only the person himself is able to establish direct contact with his inner world.
Fluent in science, Skinner added that a full description of the “world under the skin”
would be provided by anatomy and physiology. It was an idea – probably very well
grounded – of what is now called the interface between Behavior Analysis and the
Neurosciences.
The “world under the skin” refers to the internal environment of the organism,
consisting of visceral, electrical, and neurochemical responses. This is a key point
of the Behavior Analysis section, as it is possible to glimpse possible relationships
with the Neurosciences. When organisms interact with the world, not only public
behaviors are influenced by this interaction, the whole organism is modified
(Skinner, 2006). Therefore, when interacting with the world, the visceral, electrical,
and neurochemical responses, constituents of the internal environment, are also
modified. And, according to Skinner, it is this organism with a modified behavior
pattern and internal environment that will behave in the future (Silva et al., 2005).
14 Interfaces Between Neurosciences and Behavior Analysis on the Use… 209

Since the internal environment is modified by interactions with the world, it is

necessary to pay attention to the possible effects of variables that can affect the
internal functions and, therefore, affect the way people will then interact with the
environment. One of these variables that affect internal functions is the psychoac-
tive substance.

Psychoactive Substance and Behavior

Harmful use and dependence on substances as well as other related problems (e.g.,
family and marital relationships, financial issues, etc.) are constant concerns in sev-
eral countries. In the United States, for example, drug addiction is proving to be one
of the most serious and costly problems for the health care system (Silverman et al.,
2008). In Brazil, a 2017 survey conducted by the Oswaldo Cruz Foundation
(FIOCRUZ) on drug use recorded that 4.9 million Brazilians (3.2% of the popula-
tion) had made use of illicit substances in the 12 months prior to data collection
(Bastos et al., 2017).
Medicines and alcohol, two legal types of substances that appear in the survey
conducted by FIOCRUZ, deserve special attention. The use of non-prescription
drugs or the use of drugs in a different manner than the one prescribed was per-
formed by 0.6% and 0.4% of the Brazilian population, respectively. The authors of
the survey described these percentages as alarming. Specifically, the results indi-
cated that about 2.3 million people presented criteria for dependence in the
12 months prior to the survey; more than four million people reported having argued
with someone under the influence of alcohol in the same period. Together with the
studies of the World Health Organization (WHO), it was observed that alcohol is the
substance that was more directly or indirectly associated with health damages that
lead to death.
Access to medication and alcohol should be of extreme concern, not only because
of the effects on the body and the social problems that can arise from its indiscrimi-
nate use, but precisely because they are substances that are easily accessible to a
large part of the population and relatively independent of age. “Easy access“can be
read, in experimental terms, as “lower cost of response”. “Difficult access“, on the
other hand, can be read as “higher cost of response”. Studies on the cost of response
show that the lower the cost required to produce a consequence, the higher the
response rate presented in that contingency compared to the response rate presented
in another contingency with a higher linked cost.1 The notion of the cost of response
then suggests that the indiscriminate use of easily accessible substances (e.g., those
considered lawful) may be greater than the use of relatively more difficult to access
substances (e.g., those considered illicit). Generally speaking, the greater the

1
See Soares, Costa, Aló, Luiz e Cunha (2017) for a review on the response cost studies.
210 M. M. A. Tsutsumi et al.

indiscriminate use of substances, the more serious the effects will be for both the
individual and society.
Knowledge about the cost of the response allows the planning and implementa-
tion of public policies that could control more closely – which does not imply the
prohibition of any kind of substance – the access of the population to licit sub-
stances, rather than the continuation of an indiscriminate fight against what is cul-
turally considered illicit and, in an equivalent way, worse. In addition, the notion of
response cost highlights the operant aspects of drug dependency, suggesting that the
excessive use of substances is a type of behavior maintained and modified by the
interaction between the organism and the environment (Silverman et al., 2008). In
line with this notion, research has shown (e.g., Chivers et al., 2008; Roll, 2005) that
interventions based on operant principles are effective in increasing the time with-
out substance use, as well as in increasing the adherence and continuity of patients
to specific treatments.
Despite the existence of a considerable body of evidence suggesting a great
effectiveness of treatments based on the principles of Behavioral Analysis for treat-
ing the use/dependence of substances, important questions remain. Silverman et al.
(2008) raised at least three issues that need to be evaluated: (1) the need to increase
disclosure of the effectiveness of procedures involving contingency management, as
well as how they are implemented, so that they are more widely known and, there-
fore, more widely used (reading volume 41, no. 4 of the Journal of Applied Behavior
Analysis is suggested here); (2) the development of more research to assess relapse-­
related variables (reading research in the areas of resurgence, relapse and renewal is
suggested here); (3) despite contingency management interventions are very effec-
tive, they do not work with some patients, demonstrating the need for research that
refines the applied procedures. For this third point, there is a greater need for knowl-
edge of physiological aspects (e.g., about the nervous system) that may be related to
unsatisfactory results. It follows, therefore, to the Neurosciences section.

Neurosciences

The neurosciences gather evidence about the functioning of the nervous system and
do so using observation techniques that focus on different units of analysis. With the
development of technologies such as electrical recording and neuroimaging, it was
possible for the first time to study the nervous system in a non-invasive way, allow-
ing the observation of its functioning in a living organism. In terms of interface
between brain and behavioral sciences, this was an important achievement, since it
is now possible to observe the activity of the nervous system while the organism
behaves (e.g., functional neuroimaging). Before that, these data were separated and
their interface only speculative. This development is strongly in line with Skinner’s
(2006) “prediction” that one day Physiology and Anatomy would provide important
data for a more complete explanation of the behavior of organisms.
14 Interfaces Between Neurosciences and Behavior Analysis on the Use… 211

Before continuing, it is important to highlight just as the Behavior Analysis sec-

tion was built, this section will start with the definition of some basic concepts in
neurosciences. This does not mean, however, that other elements cannot or are not
part of the interface between the two areas.

Some Units of Analysis in Brain Sciences

Cells

Ramon y Cajal and Camilo Golgi shared the Nobel Prize in Physiology or Medicine
in 1906 for their proposal that the anatomophysiological unit of the nervous system
would be the neuron. Golgi’s staining technique allowed the observation that the
cytoarchitecture of the nervous tissue was composed of numerous cells of uncon-
ventional formats that maintained a specialized communication among themselves.
Later, this communication was called synapse.
Neurons have an important structural configuration to be described, since only
by understanding their structure is it possible to understand the functioning of the
next unit of analysis treated in this chapter, the neuronal communication. Neurons
are composed by a polarized (i.e., intracellular medium with negative charge and
extracellular medium with positive charge) plasmatic membrane, which is lipopro-
teic and selectively permeable and by structures immersed in the cytoplasm and
responsible for its functioning, the organelles (Junqueira & Carneiro, 2008;
Schwartz et al., 2014). Despite different morphologies, in general neurons have
dendrites (i.e., prolongations that contain proteins called receptors), cell body (i.e.,
region that contains the cell nucleus and other organelles), axon (i.e., extension
wrapped in a layer called myelin sheath, which aids in conducting the electrical
signal), and axon terminal which stores vesicles containing neurotransmitters
(Junqueira & Carneiro, 2008; Lent, 2002; Machado & Haertel, 2014).
Although neurons are the best known, they are not the only components of ner-
vous tissue. Glial cells take different forms and names, but basically, their function
is to protect and nourish neuronal cells. They are more numerous than neurons
themselves (Junqueira & Carneiro, 2008; Kolb & Whishaw, 2001b; Lent, 2002).
Without the existence of glial cells, the existence of neurons would be
compromised.

Neural Communication

The specialized communication that Ramon y Cajal and Golgi (Andres-Barquin,

2001; Ramon y Cajal, 1995) suggested came to be called synapse, which means
connection/communication between two neurons (i.e., pre and postsynaptic) or
212 M. M. A. Tsutsumi et al.

between a neuron and an effector cell (e.g., muscle cells or glands). This connection
is made between different structures of neurons: (a) contact between the axon of one
neuron and the dendrites of another (i.e., axodendritic synapse), (b) contact between
the axon of one and the cell body of another (i.e., axosomatic synapse), and (c)
between axons (i.e., axoaxonic) (Kolb & Whishaw, 2002b; Lent, 2002; Siegelbaum
& Kandel, 2014). Calling it “communication” usually leads to the interpretation that
neurons “exchange information”. Next, what neuroscience calls “exchanging infor-
mation” will be operationalized.
The “information” exchanged in the connection can be (a) ions that pass from the
presynaptic neuron to the postsynaptic through the so-called gap junctions, which
are channels that form in the physical contact between the two cells, which charac-
terizes the electrical synapses, or (b) chemical compounds that are launched into
space between neurons (i.e., synaptic cleft) and which, when attached to receptors
in the postsynaptic neuron, have the ability to alter the polarity of the plasma mem-
brane (Kolb & Whishaw, 2002a; Lent, 2002; Siegelbaum & Koestner, 2014). The
“message” that the target cell receives can be of inhibitory, excitatory, or modula-
tory type, which depends on the neurotransmitter-receptor combination.

Neurotransmitters

Different types of neurotransmitters will lead to different responses depending on

this neurotransmitter-receptor combination (Schwartz & Javitch, 2014). Among
amino acids, for example, glutamate, when binds to the receptors of the target cell,
causes depolarization of its plasmatic membrane, characterizing its excitatory
effect. The gamma-aminobutyric acid (GABA) is an amino acid that causes hyper-
polarization of the membrane of the target cell producing an inhibitory effect.
Neuropeptides (e.g., opioids) and amines (e.g., dopamine and serotonin) are neu-
rotransmitters that can have many types of effects depending on the type of receptor
they bind and their localization (Kolb & Whishaw, 2002a; Lent, 2002; Schwartz &
Javitch, 2014).

Anatomophysiology

The excitatory or inhibitory effect on neuronal activity has different impacts on the
functioning of the nervous system depending on the region to which these neurons
belong. There are some ways to divide the human nervous system didactically.
Using anatomical criteria, the nervous system is divided into central (CNS), com-
posed by the brain and spinal cord, and peripheral (PNS), composed by nerves,
ganglia, and nerve endings. Employing functional criteria, it is divided into somatic
(SNS), which participates in the interaction between the organism and the external
environment, and visceral (VNS), which relates the control of the internal
14 Interfaces Between Neurosciences and Behavior Analysis on the Use… 213

environment of the organism (e.g., viscera, glands, smooth muscle or heart muscle).
Both are divided into an afferent and an efferent component. In SNS, the afferent
component is the route in which information from peripheral sensory receptors
reaches the nerve centers, and the efferent component takes information from the
nerve centers to the striated skeletal muscles that participate in voluntary move-
ment. In the VNS, the afferent component is the route in which information coming
from the internal structures of the body is forwarded to the CNS and the efferent
component takes information in the opposite direction, from the CNS to the internal
structures (Machado & Haertel, 2013a, b). This last component of the VNS is called
autonomomic nervous system (ANS) and is divided into sympathetic and parasym-
pathetic. More recently, the enteric nervous system (ENS), which characterizes the
intrinsic innervation of the ANS by connecting the CNS to the gastrointestinal tract,
was included in this division of the ANS (Machado & Haertel, 2013a).

Reward System

The physiological response to events that increase the future probability of a behav-
ior is of vital importance for the normal functioning of any individual in his interac-
tion with the environment and can be altered in several disorders. The set of neuronal
circuits activated in these situations is known as the reward system. When, in a
given context, a behavior results in a reinforcement, an associative learning is estab-
lished between that behavior and that reinforcement. Thus, in future opportunities,
that context will tend to evoke a similar response. This type of associative learning
takes place thanks to the activity within the reward system. A key element for the
occurrence of this learning is the release of dopamine through the pathway from the
ventral tegmental area (a nucleus with dopaminergic neuron bodies) to the accum-
bens nucleus (one of the base nuclei, which is a set of structures involved in motor,
motivational, and emotional aspects of behavior). The integrity of this system is
essential for associative learning between context, behavior, and consequence (Kolb
and Whishaw, 2002a). Drugs of abuse, by directly or indirectly altering the func-
tioning of this system, produce an important part of their behavioral effects.

Psychoactive Drugs

In pharmacology, the drug is a term used to refer to chemicals that alter the body
having a beneficial or adverse effect, which only occur if there is sufficient concen-
tration of this substance in the blood for action in a tissue that has receptors for it
(Rang et al., 2016c; Stahl, 2014). It is essential to understand that the relationship
between drug and receptor is central to the changes that occur in the body. As men-
tioned above, receptors are cellular components (i.e., proteins) that interact with
substances (e.g., drugs or neurotransmitters) and are the beginning of a series of
214 M. M. A. Tsutsumi et al.

biochemical events that result in certain effects. Drugs penetrate the CNS in differ-
ent ways depending on the type of administration (e.g., oral, inhalation, rectal sup-
positories, skin patches, injectables into the bloodstream, muscles, etc.). The
absorption of drugs is also affected by their physical and chemical properties, as
well as the age, sex, and body weight of the individual (Rang et al., 2016d;
Stahl, 2014).
Drugs influence the chemical exchanges that occur in synapses and, to under-
stand their effects, it is important to look at how they modify the connection between
neurons and target cells. Each of the stages of neurotransmission includes a chemi-
cal reaction that can be influenced by the increase (i.e., agonists) or decrease (i.e.,
antagonists) in the efficiency of this neurotransmission (Rang et al., 2016d). For
example, drugs that lead to greater release of dopamine into the synaptic cleft, block
its reuptake or inactivation are considered dopamine agonists. By remaining in the
synaptic cleft, it spends more time stimulating the postsynaptic neuron. Substances
that block the production of dopamine or accelerate its inactivation are considered
to be its antagonists because they decrease the biochemical effect on synapses
(Stahl, 2014). Psychostimulants such as cocaine and methamphetamine are drugs
that alter the neural release of dopamine and the number of its receptors (e.g., D2
receptors). This makes this neurotransmitter spend more time stimulating the post-
synaptic neuron, something that is part of the explanation of the behavior changes
that are seen in users of these substances (e.g., euphoria, suppression of appetite,
mood swings). These substances also activate noradrenaline receptors that are
related to increased heartbeat, pupil dilation, and body preparation for fighting or
escape, functions that are under the responsibility of ANS (Guimarães, 2008; Kolb
& Whishaw, 2001a).
Describing and identifying the chemical reactions that occur in synapses is part
of one of the levels of explanation of behavior. By saying that there are changes in
communication between neurons and that this occurs due to drug influences, the
altered behavior is not explained, but only part of it. If the behavior is understood as
a response of the organism in interaction with the environment, it makes no sense to
assume that one level of analysis is sovereign over the other. This presumption can
fall into so-called reductionism, whatever it is. The consumption of psychoactive
substances is an example that can be analyzed within each of the different levels
and, therefore, different levels of causality can be identified. The correlation between
the use of psychoactive drugs and the change in behavior (e.g., mood, thoughts, and
emotions) can be explained from the changes that these substances trigger in syn-
apses. There may be an increase or decrease in the release of a certain neurotrans-
mitter, in the reuptake of others, in addition to altering the number of receptors in
postsynaptic neurons. This same correlation can be seen from the behavioral point
of view when one considers that the behavior emitted, when the biological appara-
tus is altered by psychoactive substances is selected from the effects it produces in
its immediate environment. The levels of analysis are not mutually exclusive, but
complementary (Kolb & Whishaw, 2001a; Lent, 2008).
CNS depressants, which can be represented by general analgesics and opioids,
hypnosedatives, antihistamines, and anticonvulsants, for example, are drugs that
14 Interfaces Between Neurosciences and Behavior Analysis on the Use… 215

reflect in behaviors such as drowsiness, muscle relaxation, and amnesia in some

cases (Rang et al., 2016a). Ethanol (e.g., alcoholic beverages) is a well-known
example for most people. It is a lawful substance and, as mentioned at the beginning
of the chapter, has a high rate of consumption and development of dependence.
Although it is not the only one, one of the targets in the CNS are the receptor regions
for the inhibitory neurotransmitter GABA, and the greater its quantity, the more
inhibitory effects on neurons in several regions are observed (Rang et al., 2016b). In
more caricatured cases of alcohol use, behavioral changes occur such as increased
social disinhibition, confused speech, unbridled walking, and loss of accuracy of
fine movements. It is possible to relate these behavioral changes to the influences
that alcohol has on hypnosedative regions of brain areas, such as pre-frontal cortex
and motor cortex (Guimarães, 2008; Machado & Haertel, 2013a).
An important curiosity of the action of alcohol is the development of tolerance,
that is, with frequent use the quantity consumed needs to be increasingly greater to
obtain the same effect as when used for the first time (Rang et al., 2016a, b). In other
words, there is a decrease in the effect over time and with frequent consumption.
Still, on CNS depressants, opioid analgesics (e.g., codeine, morphine, and heroin)
are another class of drugs that inhibit the functioning of some brain regions, but they
act on special μ receptors that are related to pain perception (Guimarães, 2008; Kolb
& Whishaw, 2001a).

A Possible Interface

After this compilation of the neuroscientific knowledge about the functioning of the
nervous system and the interference of drugs in it, as well as the presentation of
some basic concepts of Behavior Analysis, it becomes possible to discuss the pos-
sibility of interface between the two areas. Aiming at objectivity and the implemen-
tation of a line of reasoning, a classical study will be used to delineate possible
relationships between Behavioral Analysis and the Neurosciences. The chosen
study was developed by Siegel, Hinson, Krank, and McCully (1982).
These authors proposed to study the tolerance developed along the use of opioids
and whether there was environmental interference in the probability of death by
overdose. When a psychoactive substance is used, a series of chemical reactions are
triggered, as seen in the neuroscience section. These reactions disturb the homeo-
static state of the organism that is phylogenetically equipped to recover the lost
balance. With the frequent consumption of the drug, anticipatory responses are elic-
ited and prepare the organism to avoid collapse when consuming the substance
(Goudie & Emmett-Oglesby, 1989; Siegel et al., 2000). For example, in the case of
psychostimulants such as cocaine and methamphetamine, which lead to increased
heartbeat, pupil dilation, and preparation of the body for struggle or escape, antici-
patory responses of bradycardia, pupil contraction, and muscle relaxation are elic-
ited. It is important to highlight here the Skinnerian notion that the historical
relations between the organism and the environment do not only change the
216 M. M. A. Tsutsumi et al.

observable behavioral pattern, but the organism as a whole (i.e., the internal envi-
ronment is also altered and starts to function in a differential way).
Extending the analysis, one must not lose sight of the fact that this organism is in
constant interaction with the environment around it. This means that the pairing
between stimuli occurs and, using the Pavlovian paradigm (classical or respondent
conditioning) to discuss tolerance, configurations of the environment in which the
drug is consumed are paired with the psychoactive substance, thus acquiring the
function of conditional stimulus (Siegel et al., 2000). On subsequent occasions, the
environmental configuration in which the drug is consumed may be sufficient to
elicit the anticipatory responses. Given genetic variability, organisms may have dif-
ferent amounts of neurotransmitters and receptors. This difference may be related to
a greater or lesser ability to present anticipatory responses, increasing or decreasing
the probability of organism collapse. The same approach serves to discuss the prob-
lems of the effectiveness of contingency management procedures described by
Silverman et al. (2008). Differences in the amounts of neurotransmitters and recep-
tors may facilitate or hinder behavioral changes promoted by treatments for sub-
stance use and dependence.
To test the application of the Pavlovian paradigm, the researchers investigated
the effect of different doses of heroin administered in different environments on the
development of tolerance and whether overdose mortality could be a failure in this
mechanism. Siegel et al. (1982) exposed groups of rats to increasing doses of heroin
(1 mg/kg, 2 mg/kg, 4 mg/kg, 8 mg/kg), and (a) for one experimental group doses
were given in the home cage and a potentially lethal dose (15 mg/kg) of heroin in
the same environment (ST – similar test), (b) for the other experimental group doses
were given in the home cage and the potentially lethal dose in another room (DT –
different test), and (c) for the control group doses of saline were given (i.e., sodium
chloride solution) in the home cage and the potentially lethal dose of heroin in the
same environment. The mortality rate of the rats after the potentially lethal injection
of heroin was 32.4% for the ST group, 64.3% for the DT group, and 96.4% for the
control group. These results suggest that when the use of the substance is made in
the same place, the environmental configuration acquires the ability to elicit antici-
patory responses that make the organism prepared to receive the doses, which ends
up making increasingly larger doses necessary to obtain the effects as if it were for
the first time. The main evidence comes from the second experimental group that,
when the location for the administration of the drug was changed, did not have the
environmental cues and, therefore, did not present the anticipatory responses, some-
thing that made the organism unprepared to receive the potentially lethal dose.

Final Considerations

As initially explained, the interface between two areas is always a difficult task.
Writing about the possible relationships between them is something even more dif-
ficult. Therefore, there is a need for further discussion between each of the topics
14 Interfaces Between Neurosciences and Behavior Analysis on the Use… 217

mentioned here. It is clear, however, that no matter how independent the sciences of
Physiology and Behavior Analysis are (Tourinho et al., 2000; Zilio, 2016), the natu-
ral world does not make this distinction and, as described by Silva (1988), an ade-
quate understanding of behavior requires knowledge in these two sciences,
especially when it comes to subjects related to the use and dependence of substances.

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Chapter 15
Behavioral Functions of Drug Use
in Marital Narratives: From Progression
to Treatment of Substance Dependence

Jaqueline Vago Ferrari and Elizeu Borloti

Introduction

This chapter describes behavioral functions in contingencies of the progression of

the use of psychoactive substances (PAS), from the beginning up to the treatment of
dependence and its outcomes, in the repertoire of substance-dependent individuals
in the course of their marital relationships. For that, the functions of the behaviors
described by substance-dependent individuals and their wives were inferred, in
narrative sequences, using the same methodological model of narrative interviews
and narrative analysis, as shown by Germano and Serpa (2008). These authors
describe that the sequences built by the narrators during the narrative interview
reveal how they model the memories of their past, how they understand the events
and their consequences and the general sense of success and failure from them
(Germano & Serpa, 2008, p. 15). They use Larivaille’s (1974) notion of the narra-
tive sequence as a quinary chronological process, because it consists of five moments
or phases, which is useful to the study of behavioral function, since it focuses on
behavioral events, antecedents, and consequents in each time. Thus, the analysis of
behavioral functions in contingencies of the history of the marital relationship with
the presence of drug use has focused on the five phases of the narrative sequence:
initial situation, disturbance, transformation, resolution, and final situation.
A behavioral analysis is an analysis of the contingencies responsible for the
occurrence of a behavior and/or for changes in it (Matos, 1999). Thus, to functionally
analyze a person’s behavior is to answer what the function of that behavior is for
that person, that is, what is the functional relationship between his behavior and the
effects it produces. Considering the five phases of the narrative sequence (Larivaille,
(1974) listed above, the behavioral analyses described in this chapter point to func-
tional elements of this sequence in a threefold contingency, a conceptual instrument

J. V. Ferrari () · E. Borloti

Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 219
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_15
220 J. V. Ferrari and E. Borloti

for analyzing relations between organism-environment (Skinner, 1953; Todorov,

1982). Among the elements of the triple contingency analysis scheme, we highlight:
(1) the previous context; (2) the response; and (3) the consequent context.
The antecedent context can play a relational function with an operant behavior due
to differences in responding because this event is present (in this case, as a
discriminative stimulus – Sd). It can also exercise a motivational function,
increasing the reinforcing value or decreasing the punishing value of the
consequence of such operant behavior and, consequently, increasing the
probability of its occurrence or the occurrence of another operant behavior
related to it (as an establishing operation – EO). Still in a motivational function,
it can invert these values, decreasing the probability of the behavior occurring
and making its consequences less attractive (like abolishing operation – AO). It
can also exercise an eliciting function (as eliciting stimulus – ES) of a respondent
which accompanies that operant (as an unconditioned stimulus – US; or as a
conditioned stimulus – CS).
The occurring response (R) may be evoked (e.g., be an operant behavior) or elicited
(e.g., be a respondent behavior) by the presence of elements from that antecedent
context. If the element acts as an Sd, an operant behavior will have an opportunity
to be emitted, also under the function of some EO; if it acts as an ES, a respondent
will have its opportunity to be elicited.
The consequent context is called the response reinforcer (or reinforcing stimulus –
Sr); it is the product or effect in the environment produced by the occurrence and
that increases its frequency. Sr is positive (Sr+) when added to the context and
increases the frequency of the behavior that added it; and it is negative (Sr−)
when it is removed from the context and increases the frequency of the behavior
that removed it.
The response of using any PAS is under the control of all these elements of the
contexts that precede and follow it (Borloti et al., 2015). Silva et al. (2001), in his
functional analysis of substance dependence, he described these elements associ-
ated with vulnerability factors (sensitization) and the phenomenon of tolerance to
the use of PAS during the addiction process. The model by Silva et al. emphasizes
sensitization and tolerance as relatively permanent changes in the central nervous
system, resulting from the recurrent use of PAS. Thus, understanding the function
of using PAS from the context of use is essential to interventions in substance
dependence. In this context, we have the substance-dependent individual’s family
members, especially the spouse. However, few studies emphasize interventions in
the substance-dependent individual’s family or family social support network
(Moraes et al., 2009). Thus, considering that elements of the family context, espe-
cially those of the marital context, can play a direct or indirect role in modifying or
maintaining the use of PAS (Bordin et al., 2004), the relevance of the study that gave
rise to this chapter asserts itself.
The objective of this chapter is to present behavioral functions involved in the
progression of PAS dependence, from the beginning of the problem regarding the
unsafe use to the search for treatment, throughout marital histories of
15 Behavioral Functions of Drug Use in Marital Narratives: From Progression… 221

substance-dependent individuals. The behaviors and their contextual functional ele-

ments were observed in narrative sequences obtained through the technique of nar-
rative analysis (Schütze, 2011). Behavior analysis was combined with narrative
analysis, integrating both methods of analysis.

Narrative Analysis in Substance Dependence: A Brief Review

Research on the love relationship of substance-dependent individuals with their

spouses has focused on many topics, highlighting family dynamics (Paz & Colossi,
2013), codependency (Coleman, 1987; Makvand et al., 2009; Van Wormer, 1990),
and domestic violence (Subodh et al., 2014; Wekerle & Wall, 2004). What happens
in a dependent’s love relationship has attracted the attention of researchers because
PAS dependence is a complex, multidetermined phenomenon that damages many
aspects of the dependent individual’s life. In the family and couple’s aspect, for
example, it can modify the social roles of members, changing their functions in the
relationship. Capistrano et al. (2013a, b) highlight conjugal violence as one of the
possible effects of these changes.
Therapeutic interventions with drug-dependent individuals consider the family
as an essential part of the context of using PAS (Spagnol, 2018). The behavior of
family members impacts the improvement or worsening of the consequences of
drug use, from recreational use, going through the use of abuse patterns and to the
use of dependency patterns. Among these family members, the wife assumes a
primary role. She usually plays a role in the stability of the healthy pattern and in
her substance-dependent spouse’s motivation to face the difficulties of the long
course of treatment (Dos Santos et al., 2007). This appears in narratives of the
relationship’s history, which in turn makes narrative analysis (Schütze, 2011) an
important theoretical-methodological proposal for understanding the contingencies
present in this story.
Schütze (2011) analysis of narratives is, in fact, a form of verbal report analysis.
This is because it is through the verbal report that the narrator recounts situations in
his life, describing and arguing about contingencies that give meaning to what he
himself produces verbally regarding such situations; and demonstrating how he
relates to all of this, in a process that Skinner (1953) would call autoclitic. Narratives,
when transcribed, produce texts about personal experiences, in other words,
descriptions of contingencies lived by individuals, who tell and interpret them
through their own personal, social, and collective histories, in a process of turning
themselves to their own. Narrative in an autoclitic manner. From the point of view
of their origin theory, however, the histories produced would be inscribed in
subjectivity and be implicated “with the space-time dimensions of the individuals
when they narrate their experiences, in the domains of education and training”
(Souza, 2008, p. 89), showing the influence of the verbal community in its modeling.
In this sense, narrating is, in addition to telling a story, telling a story about who-
ever narrates it. Therefore, in reports of substance-dependent individuals and their
222 J. V. Ferrari and E. Borloti

wives about their relationship histories, the paths of each spouse and how they are
aligned in making a couple are described. Consequently, the contingencies described
in these narratives make it possible to focus on the behavioral functions that materi-
alize the spouse’s involvement with the PAS on which he is dependent. The impor-
tance of analyzing the contingencies in the analysis of narratives of these couples is
emphasized because they allow the observation of relationships between events that
define the different stages of the marital relationship, its beginning and its general
and specific crises, arising from the progression of the PAS pattern of use, including
changes in behavior with the gradual establishment of addiction. Even with this
merit, studies of narrative analysis with substance-dependent individuals, single or
married, have been uncommon. There are no studies combining functional analysis
of behavior and narrative analysis.
Only one study of narrative analysis of substance-dependent individuals was
found, the one by Hanninen and Koski-Jannes (1999), which analyzed autobio-
graphical narratives of individuals who stopped using alcohol, multiple drugs, and
tobacco, and have managed situations of binge eating, sexual compulsion, and path-
ological gambling. Its authors are not behavior analysts, however, due to the way
they categorized the verbal report (narrative) according to what was described by
the narrators, the key contingency for the recovery of dependency is abstracted, in
tacts of feelings and emotions and rules on causality, morality, and ethics involving
the behavior of using PAS. The verbal report of the dependent participants indicated
five self-narratives that followed a chronology in the path of coping with addiction:
history of Anonymous Alcoholics; the growth history; the history of codependency;
the love history; and the mastery history. As these self-­narratives were repeated in
the verbal report of all the participants, the authors agreed on a collectivity of factors
of the life path in the PAS dependence.
Apart from the study by Hanninen and Koski-Jannes (1999), national investiga-
tions of romantic relationships involving substance-dependent individuals do not
exist, a methodological fact that endorses the relevance of this study. It is also added
that there is a scarcity of studies comparing populations of couples dependent on
alcohol and those dependent on multiple substances, among the few that compare
individuals. De Moura Kolling et al. (2007), for example, compared individuals
dependent on cocaine/crack and alcohol/cocaine/crack, finding a high frequency of
Personality Disorder in the latter. They related this to alcohol dependence and
indicated the need for further research on emotional and personality changes in both
groups for better planning of preventive and therapeutic programs.

Methodology

The behavioral functions inferred from verbal reports of clinical cases presented in
this chapter were inferred from data from narrative analysis. In turn, the analysis of
narratives, following the theoretical framework proposed by Schütze (2011), was
obtained from multiple case studies with couples. Multiple case studies were chosen
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 223

because they make it possible to detail and systematize circumstantial information

about more than one case (Patton, 2002) at a defined time and place (Ventura, 2007).
Added to these advantages is the possibility of the case study allowing an increased
understanding of the contemporary real phenomenon of marital relationship
(Miguel, 2007) by its description (Eisenhardt, 1989; Roesch, 1999). Thus, this
chapter tells the story of a current or past event, that is, the marital relationship,
through the narrative interview as a data collection procedure (Voss et al., 2002).
In the area of international research involving romantic relationships in the con-
text of drug dependence, the case study was employed by Wetchler and DelVecchio
(1996). After observing Systemic Couples Therapy (SCT) sessions in couples with
heroin-dependent wives, the authors concluded that SCT produced changes in the
wives’ behavioral repertoire, both in using the substance and in negotiating or coop-
erating in marital conflicts. In national surveys, the case study was used to under-
stand the marital dynamics (Santos & Costa, 2004), domestic violence (Torossian
et al. 2009), individuality and conjugability (Levandowski et al., 2009) in typical
couples and also couples of specific groups, such as riverside couples in the Amazon
region (Silva et al., 2011).
The analyses presented in this chapter describe the couple’s history by identify-
ing and analyzing the narrative sequences in the verbal reports of both husband and
wife, highlighting the descriptions of contingencies evoked in their reports as they
are representative parts of the whole history of their relationship. In behavioral
terms, the narrative sequences that involve these contingencies are sets of verbal
operants involving those who behaved in a time and space from a conflict over the
use of the PAS. That said, the model of analysis of narrative sequences, as exposed
by Germano and Serpa (2008), was used as the basis in this chapter, using Larivaille’s
(1974) notion of narrative sequence: initial situation, disturbance, transformation,
resolution, and final situation. Thus, what follows next is an analysis of such
sequences considering the history of the marital relationship with the progression of
drug use, from addiction to its treatment.
Participants were selected in the Health Rehabilitation Program for Substance-­
Dependent Individuals and Alcoholics (Presta, in Portuguese), at the Military Police
Hospital, located in the city of Vitória (ES). Presta offers specialized treatment for
substance dependence, focusing on improving self-esteem and rebuilding the life
project of patients, military personnel, their families, and community members.
Four couples participated in the study (NTOTAL = 8), included according to the
following criteria: (a) in a relationship for over 5 years; (b) at least in a civil union;
(c) in which one of the spouses has been diagnosed with F10.21 (2 couples) or with
F19.22 (2 couples); (d) and the spouse was undergoing specialized follow-up on an
inpatient or post-discharge basis at Presta. Exclusion criteria were: (a) Personality

1
Mental and Behavioral Disorder due to alcohol use – dependency syndrome.
2
Mental and Behavioral Disorder due to alcohol use – dependency syndrome.
224 J. V. Ferrari and E. Borloti

Disorder (F60);3 (b) Intellectual Disability (F70), Mild, moderate and severe
Cognitive Disorder (F06.7) and Dementia (F0);4 and (c) Schizophrenia (F20).5
Some spouses included as participants were in the treatment process; others, in
post-discharge. They were all heterosexual. Order of marital union, income, religion,
paternity/maternity, and psychological treatment were not exclusion criteria.
The narrative interview was used as the main instrument for data collection for
the analysis of narratives and, from it, for the analysis of behavioral functions. The
narrative interview aims at reconstructing the verbal repertoire, in general intraverbal,
contingencies (events), according to the experience of the interviewees, who are
encouraged to retell the story of scenarios of significant moments in their lives.
(Bertaux, 2010; Bruner & Weissner, 1995) Schütze (1983), according to
Jovchelovitch and Bauer (2002, p. 105), affirms the instrument’s trans-theoretical
aspect: “it is a technique for generating stories; it is open regarding the analytical
procedures that follow the data collection”. For this reason, the data collected
through these interviews can be subjected to an analysis of contingencies, inferred
from the responses to the same “narrative-generating question”6 which initiates the
interviews (Riessmann & Schütze, 1991, p. 353).

Data Analysis Procedures

The analysis process of the narrative interviews was carried out based on the com-
plete proposal by Schütze (2011), which includes the following stages of analysis:
(a) Identification of the indexed and non-indexed elements;7 (b) Analysis of the
indexed elements;8 (c) Analysis of non-indexed elements9, and (d) Contrasting

3
Because such disorders indicate persistent patterns that cause impairment in social, occupational,
or other important areas of an individual’s life (American Psychiatric Association, 2014).
4
Due to the fact that this investigation required responses prepared by the participants in order to
achieve the expected objectives.
5
This diagnosis consists of a set of signs and symptoms associated with impaired professional or
social functioning, which could interfere with the objective of the study (American Psychiatric
Association, 2014).
6
“I would like you to tell about the story of your love relationship, from the day you met, through
the establishment of the relationship to the present day”.
7
The indexed elements are those that make concrete reference, within the narrative, to the markers
of: Who did it? What? When? Where? Why? Non-indexed elements, on the other hand, are those
that express values, judgments and a generalized form of “life wisdom”. The distinction between
indexed and non-indexed elements of each narrative serves to signal that the story told by the
interviewee goes beyond the chronological sequence of the narrated events, also expressing itself,
by functions, meanings and self-understandings that the narrator makes of his path.
8
Analysis of the couple’s history through the identification and analysis of the narrative sequences,
highlighting the events that were evoked by the couple to be described as part of the whole (the
history of the relationship).
9
Analysis of each segment of the narrative in order to identify the descriptive, argumentative and
explanatory propositions of the report, which refer to how the narrators report external events
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 225

comparison,10 as presented by Ferrari (2019). However, this chapter presents only

part of this analysis: the analysis of indexed elements based on the identification of
narrative sequences. After identifying the narrative sequences, behavioral functions
were inferred from them in contingencies related both to the progression of the pat-
tern of PAS use of substance-dependent husbands regarding the search for a solu-
tion (treatment) and the maintenance of the results of that solution (in this case,
abstinence). The following are the procedures for the two analyses conducted
together.

Analysis of the Elements Indexed in the Couples’ Narratives

The analysis of the elements indexed in the narratives was the decomposition of the
couple’s history with the dependence on the PAS, through the identification of their
narrative sequences, highlighting the events that were evoked in the members’
repertoire and described as part of the whole of the history of their love relationship.
For this, the model exposed by Germano and Serpa (2008) was used to explain
events described in autobiographies (in the authors’ study, of young people in
conflict with the law).

 nalysis of the Functional Elements of the Contingencies

A
of the Progression of the PAS Use Pattern

The analysis of the functional elements of the contingencies of the progression of the
PAS use pattern was the decomposition of the behavioral functions narrated in the
chronological process of PAS dependence, and their antecedents and consequents,
according to the A-B-C model (antecedent-behavior-consequence model). The
antecedents As are the Sd’s, the EOs, the AOs, and the ESs (which could have
functioned as US’s or CS’s, but which were not distinguished). The Rs, behaviors,
or classes of responses observed were described by the responses related to the
PAS. These responses are not always made explicit in the narratives, and have
sometimes been inferred from the context and effects of use, in antecedent and con-
sequent events. The Cs, consequences, are Sr+ (Positive reinforcement), Sr−
(Negative reinforcement), Pn+ (Positive punishment), and Pn− (Negative
punishment).

(changes, mourning, labor issues, etc.), their reactions, understanding or interpretation of

these events.
10
Contrasting comparison is a analysis of each segment of the narrative in order to identify the
descriptive, argumentative and explanatory propositions of the report, which refer to how the nar-
rators report external events (changes, mourning, labor issues, etc.), their reactions, understanding
or interpretation of these events.
226 J. V. Ferrari and E. Borloti

Clinical Cases

Table 15.1 shows the main characteristics of the participating couples.

Couples 1 and 2 are made up of husbands with alcohol dependence (ICD F10)
and couples 3 and 4 are made up of husbands with addiction to cocaine and multiple
drugs (ICD F14 and ICD F19). Wives have no substance dependence.
Couple 1: Jean and Lara. Couple 1’s husband, Jean, was addicted to alcohol, was
58 and his wife, Lara, was 53. They had been married for 29 years and were the
parents of two children. They were contacted when they were at Presta to
participate in post-discharge activities (she, at least once a month; he, every
15 days, since 2008 when he was hospitalized). The couple reports maintenance
of abstinence by their husband since 2008, even when they experienced the loss
of their youngest child, 5 years ago, in a car accident. This loss strengthened the
spouses’ bond with Presta, due to the psychological support received, while still
remembering the fact, which still touched them very much.11
Couple 2: Maurício and Helena. Couple 2 was formed by Maurício, the 53-year-old
husband with alcohol dependence, and his wife, Helena, 55. They had been in a
relationship for 28 years, with 2 biological children and an adopted daughter.
Maurício and Helena were approached on the day they were at Presta to partici-
pate in post-discharge activities. Unlike Couple 1, Maurício and Helena partici-
pated together at least once a month after discharge, since 2013, when Maurício
was hospitalized. According to him, since the end of this hospitalization there
had been no (re) occurrence of alcohol use by him; she, in turn, believed that he

Table 15.1 Characteristics of participating couples

Relationship Amount of
Group Couple Fictitious names Age durationa children
Alcohol Couple 1 Jean and Lara 58 e 29 years 2 children
53 years
Couple 2 Maurício and 53 e 28 years 3 children
Helena 55 years
Multiple Couple 3 Ícaro and Joana 34 e 9 years None
substances 24 years
Couple 4 Márcio and 52 e 22 years 3 children
Nilda 45 years
From the beginning of dating to the present day
a

11
Some of Jean’s cognitive and behavioral characteristics influenced the interaction with him in
narrative interviews. He repeated words and the evocation of those seemed compromised. He also
demonstrated a flight of ideas, as he started answering content evoked by the narrative-generating
question and continued or ended with other content, especially in the individual interview. The first
author of this chapter had to repeat the question for Jean to verbally issue the narrative related to
the objective of the study.
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 227

would have used alcohol between 2017 and 2018, during a sergeant course in
Vitória.
Couple 3: Ícaro and Joana. Couple 3 was made up of Ícaro, with Cocaine
Dependence, 34 years old, and Joana, 24 (they had no children). After 9 years of
relationship, they lived together for 5. He was a military policeman; she, a
saleswoman. Like Couples 1 and 2, they were also found in post-discharge
activities, where they had always been together since 2017, when Ícaro was
hospitalized. Ícaro and Joana reported that since the end of hospitalization, in
2017, there was no (re) occurrence of the use of cocaine by Ícaro, nor of tobacco
or alcohol, which used to also be consumed before hospitalization.
Couple 4: Márcio and Nilda. Márcio, 52, and his wife, Nilda, 45, made up Couple
4, and he was diagnosed with Cocaine Dependence. They had been in a
relationship for 22 years, and in that time they had three children. The couple
was contacted when Márcio was hospitalized and both he and she were receptive
to the interviews, a fact that perhaps justified the fact that they were thorough in
their responses. Added to this were the specific characteristics of the spouses:
both were military police officers with higher education (she, in one of the human
sciences). Márcio was in the hospital for only 2 weeks when the couple was
interviewed, and Márcio’s use of alcohol is always present in the history of his
relationship with Nilda. Although, through the Presta system, Márcio was
diagnosed with Alcohol Dependence, in the interviews he shared that he
combined the uses of alcohol and cocaine, given that the couple belonged to the
group related to CID F14 and CID F19.

 escription and Behavioral Analysis in Narrative Sequences:

D
From Progression to the Treatment of Substance Dependence

The narrative sequences of the stories of marital relationships in clinical cases cor-
respond to descriptions of relationship phases in the progression of substance use:
from its beginning (recreational/abusive use) to its end (treatment). Such sequences
(Larivaille, 1974) serve behavioral analysis (Fig. 15.1).

Initial Situation: The Beginning of the Love Relationship

Table 15.2 presents the indexed elements of the narrative sequence and the behav-
ioral functions for using the PAS in the beginning of the couples’ romantic
relationships.
228 J. V. Ferrari and E. Borloti

Fig. 15.1 Figure based on the model of Larivaille’s model (1974) for analysis of narrative sequences
Legend: Initial Situation (beginning of love relationship); Disturbance (relationship between criti-
cal points of the PAS use and the love relationship); Transformation (behavior change and its
impact on the couple’s life); Resolution (substance dependence treatments and other attempts to
solve the problem); Final situation (maintenance of the problem solution repertoire)

 isturbance: Relationship Between Critical Points of the PAS

D
Use and the Romantic Relationship

Table 15.3 shows the indexed elements of the narrative sequence of the disorders
that the PAS use produced in the love relationship, in its antecedent and consequent
behavioral functions.

Transformation

Table 15.4 presents the indexed elements of the narrative sequence of the transfor-
mations that the PAS use causes, with its antecedent and consequent events. It is
possible to observe how this use changed the marital relationship of the participat-
ing couples.
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 229

Table 15.2 Initial situation of the marital relationship and use of PAS: Narrative Sequence and
Behavioral Functions
Behavioral functions in the initial
Couple Narrative sequence situation
1 In a city in the countryside of Espírito Santo state, Deprivation condition due to
Lara and Jean met when he was having a financial issues and the reduction
relationship with her friend. He breaks up with this of living standards (EO)
friend because he started being interested in Lara, Housing condition in a
who had the condition of only dating him if he was metropolitan region (EO)
single. After 1 year of dating the couple started The condition of mutual
organizing the wedding, which took place with a ignorance (“being a young
party, preceded by a bridal shower. In 1990 the first couple”) of the dependency (EO)
child of this “young couple” was born. With no Presence of social occasions for
experience, the couple faced financial issues drinking (Sd and ES)
(described by Lara as a problem in Jean’s family). “Whenever I have an
As a solution, they had to sell their cars, other goods opportunity, if I drink socially,
and live in a city in the metropolitan region of the then there will be no problems”
state. Living in this city, on many occasions, Jean (Jean’s rule, also functioning as
drank “socially” with friends, according to him; an EO)
according to Lara, he already drank a lot and, also Presentation of the affection
according to both, “without a clue what it was” from his friends (Sr+).
(alcoholism). For her, this “lack of notion” was due
to them being a young couple and still getting to
know each other, since it was only afterward that
they discovered that it was an addiction.
2 The couple met in 1990 at a club. He and she began The condition of permissiveness
living together shortly after Helena’s employer by the wife, for 15 years, of
became aware of the relationship between them, and problematic drinking (EO)
did not approve it because Maurício was a police
officer. After a year living together, Helena got
pregnant. They got married. After the wedding, in
less than 1 month, the couple’s first child was born.
Helena only recognized alcohol use as a problem in
2005.
3 Joana was introduced to Ícaro in 2013 by his The condition of unawareness of
brother. After a few months, they started dating. In the dependency by the wife (EO)
2013, Ícaro already used the PAS, albeit in a smaller The wife’s presence (Sd and ES)
quantity, and managed to hide it from Joana, using it Snorting less cocaine (R1 of
where she couldn’t see it. Joana was not aware of removing aversive stimulation)
what cocaine was and only learned that Icarus was Snorting cocaine in a location
using it when the condition of dependence unseen by the wife (R2 of
worsened. removing aversive stimulation)
Reducing the probability of the
wife “finding out about the use”
and presenting aversive
stimulation, such as criticism, or
removing reinforcers, such as
affection (Sr−)
(continued)
230 J. V. Ferrari and E. Borloti

Table 15.2 (continued)

Behavioral functions in the initial
Couple Narrative sequence situation
4 Nilda and Márcio met during an officer training The condition of unawareness of
course. They started going out and afterward dating. the dependency by the wife (EO)
In a year of dating, they got engaged and moved in The wife’s presence (Sd and ES)
together. At the end of the course, they got married. Snorting cocaine in location
At the beginning of the relationship, Nilda did not unseen by the wife (R of
realize Márcio used cocaine, which was consumed removing aversive stimulation)
by him unnoticed by her, who discovered the use of Reducing the probability of the
cocaine at a party at Márcio’s parents’ house. Since wife “finding out about the use”
then, they began talking about the use. and presenting aversive
stimulation, such as criticism, or
removing reinforcers, such as
affection (Sr−).
Talk about the use of cocaine (R
from both, approaching a
solution to the problem)
Note: Sd discriminative stimulus, EO Establishing Operation, ES Eliciting Stimulus, Sr+ Positive
reinforcement, Sr− Negative reinforcement, R Response

Resolution

Table 15.5 contains the indexed elements of the narrative sequence of possible reso-
lutions for the use of PAS in romantic relationships based on their consequences. It
also shows the background to the behaviors involved in these resolutions.

Final Situation

The indexed elements of the narrative sequence of the final situations regarding the
impact of the PAS use on love relationships are in Table 15.6. In it, we can find the
elements of the antecedent context of the responses related to this outcome.

Discussion

In the narrative sequences, the behavioral functions appeared in common contin-

gencies during the progression of the use of PAS by spouses dependent on alcohol
(Couples 1 and 2) and multiple substances (Couples 3 and 4). It stands out, in alco-
hol-dependents, that this progression, during the marital relationship, was favored
by the late perception of the alcohol use as harmful/problematic from the wives and
other family members. This late perception marks the narrative sequences of the
Initial Situation and the Disturbance. In multiple substance-dependents, their wives’
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 231

Table 15.3 Disruption of the marital relationship and the PAS use: Narrative Sequence and
Behavioral Functions
Behavioral functions in the
Couple Narrative sequence of disturbance disturbance
1 Jean and Lara returned to the countryside of A strong friendship with individuals
the state of Espirito Santo, after receiving a who drink (EO)
proposal from Jean’s uncle for Jean to The frequent presence of friends who
become a caretaker. As in the metropolitan drink (Sd and ES)
area, Jean also drank in the countryside and “When I feel like quitting drinking, if
had friends who also drank. Jean quit I try to, then I will be able to quit”
smoking “overnight”, but in relation to (rule, also functioning as an EO)
drinking, as he had no desire to quit “and so The presentation of affection from his
did not try to”. Friendships in the countryside friends (Sr+).
made it harder to quit drinking, which became
very frequent.
2 In 2005, the whole family realized that The condition of late knowledge of
Mauricio’s alcohol use had become daily and alcohol dependence by the wife and
of imminent risk. He suffered a heart attack children (EO of approaching a
after a party and, at the hospital, it was solution to the problem)
revealed that the cause was the use of alcohol.The condition of health deterioration
Helena took care of him in this and other (EO of approaching the problem)
The condition of acceptance of
critical health episodes, also due to the use of
alcohol. After these episodes, there was alcohol dependence by the family (EO
acceptance by the whole family of Maurício’s of approaching a solution to the
alcoholism as a problem. Maurício was very problem)
confident in his wife’s protection. Presence of a caregiving wife during
critical health episodes (Sd)
“When, and whenever I need, if I have
health problems, then I will get taken
care of by my wife” (rule, also with
the function of EO for drinking).
3 The PAS use progressed to the pattern of The condition of poor social
abuse after Ícaro moved in with Joana, as it surveillance (EO for snorting)
was easier to hide it from few people. Nobody Snorting cocaine in a place unseen by
was watching him as they did when he lived the wife and mother-in-law (R of
with his parents. Living with Joana, he needed removing aversive stimulation)
to hide the use only from her and his Reducing the probability of the wife
mother-in-law. The worsening of substance and mother-in-law “finding out about
dependence started to become concerning. the use” and presenting aversive
stimulation, such as criticism, or
removing reinforcers, such as
affection (Sr−)
Thinking about the worry pattern
“what if it gets worse?” (R of
approaching the solution to the
problem)
“When I feel like snorting, if I do,
then the problems will get worse”
(rule, also functioning as an AO for
the cocaine use)
(continued)
232 J. V. Ferrari and E. Borloti

Table 15.3 (continued)

Behavioral functions in the
Couple Narrative sequence of disturbance disturbance
4 In 2002 the couple’s arguments increased. The condition of conflict
The frequency of the consumption pattern of intensification in the marital
substances by Márcio increased, following the relationship (EO for snorting)
increased stress in his service. He and Nilda The condition of intensification of
were involved in arguments for several stressors at work (EO for snorting)
reasons. One of these arguments seems to The presence of reasons for conflict in
have been related to the premature birth of the the relationship (Sd and ES)
couple’s second daughter, because soon after The presence of reasons for stress at
it, Nilda got sick, and the childbirth was work (Sd and ES)
anticipated. Márcio was also involved in a Arguments with the wife (R1 of
conflict with a man in a bar, who he shot with escaping aversive stimulation)
his firearm. Shooting a man with a gun (R2 of
escaping aversive stimulation)
Reducing the likelihood of
maintaining aversive stimulation (Sr−)
Note: Sd discriminative stimulus, EO Establishing Operation, ES Eliciting Stimulus, Sr+ Positive
reinforcement, Sr− Negative reinforcement, R Response

perception of use was also non-existent in the Initial Situation, due to the substance-
dependent husbands’ strategies to hide their use (Sr−), motivated by their lack of
knowledge about what the illicit substance was (EO). From the content of such
sequences, one can see that the wives were unaware of the substance dependence,
therefore, they did not act to prevent the progression of consumption (Sr). It is then
confirmed what Edwards et al. (2005) point out: the perception regarding the harm-
ful use pattern comes up when the family dynamics is compromised by the sub-
stance-dependent family member’s behavior. Given that the group dynamics
involves, among the variables described by communication theorists (Cf., Fulk &
Boyd, 1991), the bond (proportion), the reach (amount) and the degree (intensity) of
affective bonds, the goal of controlling the consumption and avoiding its negative
consequences becomes the daily concern of family members in maintaining group
dynamics.
It should be noted that the wives’ late perception of their husbands’ problematic
alcohol consumption may also be associated with the idea presented by Ronzani
and Furtado (2010). The authors refer to society’s ambiguous way of dealing with
the use of alcohol: on the one hand, there is an incentive and glamorization of the
use of alcohol by groups, by the media, and by Brazilian culture; on the other hand,
when consumption becomes a problem, this use has a negative connotation and is
associated with moral weakness, making the alcohol-dependent condemned to
exclusion and a series of judgments.
The immediate support of the husband when it comes to excessive alcohol intake,
lying to relatives and neighbors about the latter’s situation and pretending to be well
are common responses in the behavioral functions presented by the wives of alcohol-­
dependent individuals in the Transformation stage. As they evade aversive
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 233

Table 15.4 Transformation of the marital relationship and PAS use: Narrative Sequence and
Behavioral Functions
Narrative sequence of
Couple transformation Behavioral functions of transformation
1 In 2008, living a very difficultThe condition of conflict intensification in the marital
relationship with Jean, Lara relationship (EO for drinking)
witnessed her husband’s The presence of her drunk husband (Sd and ES, for
drinking, but pretended that Lara)
the situation was fine and lied Saying “I’m fine” (concealing aversive feeling)
to relatives and neighbors (Lara’s R1, escaping aversive stimulation)
when they asked her about the Lying (Lara’s R2, escaping aversive stimulation)
situation Jean was facing with Presence of questions about how the husband faces
drinking. It was difficult for the drinking problem (Sd and ES)
Lara to be in the relationship Reduced likelihood of presenting aversive stimulation
because of his behavior. (Sr−)
2 The relationship between The condition of conflict intensification in the marital
spouses has become more relationship (EO for drinking)
difficult due to alcohol The presence of conflict in the relationship (Sd and
dependence, with some ES).
conflicting situations. Drinking (excessively) (R from Maurício, escaping
Maurício started drinking aversive stimulation)
alcohol excessively. Helena Providing immediate help to the husband for
helped her husband when he excessive alcohol intake (R from Helena, escaping
was ill after these excessive aversive stimulation).
alcohol intakes. Reduced likelihood of presenting aversive stimulation
(Sr−)
3 Ícaro, having missed days of Aversive condition of punishment at work (EO for
work, responded to an snorting cocaine and getting away from people)
administrative process. He The presence of an administrative process at work (Sd
started distancing himself and ES)
from Joana, who felt lonely The condition of conflict intensification in the marital
even when he was home. He relationship (EO for snorting cocaine)
used to go clubbing without Being home without her husband’s company (ES for
his wife and, being there, Joana, eliciting a feeling of loneliness)
ended up using drugs. The Feeling of loneliness at home (R from Joana)
relationship between them was Presence of a situation of disagreement with the wife
getting very bad. Situations of (Sd and ES)
disagreement ended in Going to clubs without his wife (R from Ícaro,
arguments escaping aversive stimulation)
Reduced likelihood of presenting aversive stimulation
(Sr−)
(continued)
234 J. V. Ferrari and E. Borloti

Table 15.4 (continued)

Narrative sequence of
Couple transformation Behavioral functions of transformation
4 Márcio used to come home The condition of receiving of city transfer request to
later than usual, quiet, and did another city (EO for snorting cocaine)
not talk to his family. He was The presence of a transfer document to another city
often transferred to work in (Sd and ES).
other cities, where he used to The presence of friends who use the PAS (Sd and ES)
go to bars and became closer Going to bars with friends (R1 from Márcio, being
to friends who also used the closer to the PAS)
PAS. The use already affected Returning home late (R2 from Márcio, escaping
the relationship and Nilda aversive stimulation)
asked him to undergo the Being silent when arriving home (R3 from Márcio,
treatment. escaping aversive stimulation)
Asking him to undergo treatment of using the PAS (R
from Nilda, approaching the solution to the problem)
Note: Sd discriminative stimulus, EO Establishing Operation, ES Eliciting Stimulus, Sr+ Positive
reinforcement, Sr− Negative reinforcement, R Response

stimulation, such escape-avoidance responses are frequently observed in family

members of substance-dependent individuals, and show an insufficiency in the rule-­
setting repertoires (boundaries) and in the defense of rights and needs, which are
usually indicators of the behavioral pattern called codependency (Bortolon et al.,
2016). Codependency is an emotionally dependent relationship between a substance-­
dependent individual and another, who is not substance-dependent. This bond, con-
sidered problematic in general, but initially functional to the relationship, causes
illness in the codependent individual, resulting in an overload and damages to the
mental health of the family caregiver, especially women, as they make up the major-
ity of care providers for substance-dependent family members (Spagnol, 2018).
The presence of a situation involving disagreement with the wife (with the func-
tion of Sd and ES) and the condition of conflict intensification in the marital rela-
tionship (with the function of EO) are present in all Transformation narrative
sequences of couples: in this phase, couples are in stages of the relationship in
which they can already describe evident losses caused by the progression of sub-
stance use. This improvement in the descriptive capacity is due to the effects of
punishment: while difficulties increase the likelihood of use creating conflict fol-
lowed by negative feelings (Pn+), they also increase the likelihood of use producing
an escape from effective communication and opportunities for resolution of con-
flicts between the couple (Pn−). In different studies of couples with a substance-
dependent individual who do not employ the description of phases of the marital
relationship, difficult moments are seen, associated with psychological distress and
a lower marital satisfaction (Kahler et al., 2003; Kelly et al., 2000; Whisman et al.,
2006), which could be equivalent to the moment of Transformation.
In the couples with individuals dependent on multiple substances, the
Transformation phase presents behavioral functions related to the work context,
such as the condition of receiving a transfer application to work in another city
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 235

Table 15.5 Marital relationship resolution and PAS use: Narrative Sequence and Behavioral
Functions
Narrative sequence of the
Couple resolution Behavioral functions in the resolution
1 Jean discovered Presta The condition of friendship and admiration of a military
through contact with a friend (EO of hospitalization)
military friend, whom he Presence of the admired military friend’s advice (Sd
liked very much. The friend and ES)
advised him to know the Feelings of excitement/acceptance for the change (R1
program. Excited, and from Jean)
wanting to prove that he Thinking “I can, and I will prove that I can improve”
would improve, Jean agreed (Jean’s R2, approaching the solution to the problem)
to be admitted at Presta in Going to the hospital (Jean’s R3, approaching the
2008. Lara and his friend solution to the problem)
were very happy with his Presentation of the satisfaction from his wife and friend
decision to treat himself. (Sr+)
2 Maurício went to Presta in The aversive condition of treatment imposition (EO for
2013, but without the staying hospitalized)
intention of staying for Forcing him to stay at Presta for a while (R from
treatment. He wanted to go Helena, approaching the solution to the problem)
home, but his wife “forced” “Since I have no intention of being admitted, if I make
him to try and stay. He it clear that I just want to know more about
stayed for 43 days. He liked hospitalization, then the others will not insist on it”
it and stayed for treatment, (Maurício’s rule, also with the function of an EO,
which made Helena very escaping aversive stimulation)
happy. Going to Presta (R1 from Mauritius, to approach the
solution to the problem)
Mild condition of hospitalization (EO for being
hospitalized)
The adherence to treatment (R2 from Mauritius,
approaching the solution to the problem)
The presentation of satisfaction with his hospitalization
(Sr+)
Presentation of his wife’s contentment (Sr+)
3 On Joana and Icaro’s The aversive condition of having previous knowledge
brother’s initiative, they both about hospitalization (AO for staying hospitalized)
got a place at Presta to The condition of the initiative of being hospitalized
hospitalize Ícaro. Since it coming from someone else (AO for being hospitalized)
hadn’t been Icaro’s idea, he Mild condition of hospitalization (EO for being
thought he would not be in hospitalized)
treatment. He went, liked it Being in the hospital environment (Sd and ES)
and stayed; and, together Adherence to the treatment (R from Ícaro, to approach
with his wife, he learned the solution to the problem)
more about substance Presentation of knowledge and learning about substance
dependence. It was good for dependence (Sr+)
improving their marital life. Presentation of improvement in his marital relationship
(Sr+)
(continued)
236 J. V. Ferrari and E. Borloti

Table 15.5 (continued)

Narrative sequence of the
Couple resolution Behavioral functions in the resolution
4 Márcio was admitted at Mild condition of hospitalization (EO for being
Presta in 2003 and in 2018. hospitalized)
Between 2003 and 2018, The adherence to treatment with hospitalization in 2018
when he was in his most (R from Márcio, approaching the solution to the
critical periods of use, he problem)
underwent treatment at a Seeking treatment without hospitalization (R from
CAPS and with independent Márcio, approaching the solution to the problem)
psychiatrists. In 2003, he The presentation of positive treatment results (Sr+)
was admitted to
hospitalization, but the
intention was to stay
abstinent only during the
period of resolution of a
lawsuit.
In 2018, he went to
hospitalization recognizing
the need to discontinue the
use, adhering to the
treatment.
Note: Sd discriminative stimulus, AO Abolishing Operation, EO Establishing Operation, ES
Eliciting Stimulus, Sr+ Positive Reinforcement, R Response

(EO), the presence of an administrative process at work (Sd and ES), the presence
of a document transferring the place of work to another city (Sd and ES), and an
aversive condition of punishment at work (EO), revealing relations between the
work routine and the progression of PAS consumption. It is relevant that the hus-
bands (dependent on multiple substances) of couples 3 and 4 were police officers, a
job especially vulnerable to physical and psychological stress. Souza et al. (2013),
when investigating military and civil police, mention problems at work (11%) and
absence from work (17.1%) as common in this group. They also report that military
police officers have a higher percentage of associated consumption of both legal and
illegal substances when compared to civilians. Capistrano et al. (2013a, b), when
identifying the social impact of drug abuse for substance-dependent individuals,
observed that in 21.7% of his sample, job losses were present and, of these, 63.2%
have already lost their job as a result of substance dependence.
Going to the hospital (R) and adhering to treatment (R) are responses of approach-
ing a solution to the problem prevalent in the Resolution phase, followed by the
presentation of Sr+s for answers on knowledge regarding substance dependence,
the perception of positive treatment results, and the contentment of the substance-
dependent individual with the hospitalization, as well as for his wife when it comes
to the treatment. Learning more about the concepts, phenomena and effects of sub-
stance dependence is an important aspect to manage the problems and for effective
15 Behavioral Functions of Drug Use in Marital Narratives: From Progressi… 237

Table 15.6 Final situation of the PAS use in the marital relationship: Narrative Sequence and
Behavioral Functions
Behavioral functions in the
Couple Narrative sequence of the final situation final situation
1 Hospitalization in 2008 at Presta. Maintenance of Maintaining weekly
abstinence and the treatment process with the wife’s post-discharge treatment at
weekly participation at Presta. Presta after hospitalization (R
from Jean and Lara, for
maintaining abstinence).
The presentation of the wife’s
contentment for maintaining
Jean’s abstinence (Sr+)
The presentation of Jean’s
contentment for maintaining
abstinence since 2008 (Sr+)
2 The husband claims a period of abstinence during the Maintaining the post-­
past 5 years. He attends Presta’s post-discharge discharge treatment every
program every 2 weeks. Sometimes with the wife. The 2 weeks at Presta after
wife reports that her husband’s aggressive behavior has hospitalization (R from
not changed, that he has just stopped drinking. She Maurício, for maintaining
believes he used alcohol during the period he was in abstinence).
Vitória, taking the sergeant course, when he The presence of the wife’s
experienced stressful situations. judgment without attempting
to solve the problem (Sd).
Maurício: Maintenance of
aggressive behaviors (Sd)
Mauricio: Experiencing
stressful situations (Sd)
3 Hospitalization in 2017 at Presta. Maintenance of Maintaining post-discharge
abstinence for 1 year and 2 months, post-discharge treatment at Presta after
treatment at Presta with his wife. They attend church hospitalization (R from Ícaro
together and live in harmony. and Joana, for maintaining
abstinence)
Going to Church (Sd and ES)
Harmonious marital living (R
of maintaining abstinence).
The presentation of the wife’s
contentment by maintaining
Ícaro’s abstinence (Sr+)
4 Márcio was still hospitalized during the interview, Adhering to treatment (R
effectively taking part in all activities. The family was from Márcio of approaching
also taking part in the treatment. the treatment’s maintenance
and abstinence after
discharge)
The family’s presence during
treatment (Sd)
Note: Sd discriminative stimulus, EO Establishing Operation, ES Eliciting Stimulus, Sr+ Positive
reinforcement, R Response
238 J. V. Ferrari and E. Borloti

responses of care and prevention of problems related to substance dependence

(Filizola et al., 2006; Rocha, 2011). The lack of knowledge regarding the substance
dependence management can lead the relatives of the substance-­dependent indi-
vidual to discourage one from changing, also holding the individual responsible for
progressing or relapsing on the use pattern, as well as strengthening the denial of the
PAS use evidence. In general, according to Rocha, these behaviors of family mem-
bers are correlated with ambivalent feelings, such as shame and guilt.
The Maintenance stage is marked by behavioral functions that involve the par-
ticipation of the substance-dependent individual (both dependent on alcohol and
multiple substances) in the continuity of treatment-related activities. In the cases
studied in this chapter, these activities are those of the Presta post-discharge follow-
up program after hospitalization. The participation of the wife (Sr+), the family’s
presence in the treatment (Sd), and the harmony between the couple (Sr+) also
prevail among couples as a function that favors the maintenance of the treatment
and the abstinence in the observed cases. The family’s effective participation in the
treatment of substance dependence is a protective factor for the substance-depen-
dent individual and a strategy for family members, also affected by the dependency,
to be cared for and gain knowledge about what to do and how to contribute to the
treatment (Paz & Colossi, 2013).

Final Considerations

The purpose of this chapter was to present behavioral functions involved in the pro-
gression of substance dependence and its treatment during the marital relationship.
The results highlighted behavioral functions of use progression as contained: in the
late perception of alcohol use as harmful/problematic by the wives; the strategies of
substance-dependent husbands to hide the use from their wives; their lack of knowl-
edge about what the illegal substance was; pretending to be well (wives), a condi-
tion of intensifying conflict in the marital relationship, the presence of a situation of
disagreement with the wife, an aversive condition of punishment at work. Among
the functions related to solving the problem, the following stand out: going to the
hospital; adhering to treatment; learning the concepts, phenomena and effects of
substance dependence; participating in the post-discharge follow-up program (sub-
stance-dependent individual); participating in the treatment (wife and family) and
contributing to the harmony between the couple.

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Chapter 16
Drugs Use in Romantic Relationship
and Violence Against Women

Vânia Lúcia Pestana Sant’Ana and Débora Barbosa de Deus

Introduction

Violence against women is a subject that must be discussed from the perspective of
developing prevention and intervention strategies that aim to curb its occurrence,
mainly due to the frequency and severity of the cases. According to the World
Health Organization (WHO), violence is understood as the “use of physical force or
power, real or threat, against yourself, against other person, or against a group or
community, that results or is likely to result in injury, death, psychological damage,
developmental disability, and deprivation” (WHO, 1996, p. 5). Although this defini-
tion covers almost all classes of aggressive behavior against women it is necessary
to recognize that this pattern is not recent nor determined by a single factor. It is
important to know historical aspects of women’s role in society and the evolution of
their representation as female gender.
In the human evolutionary process, men begin to exercise control over women
when they discover their role in conceiving children. This discovery meant that men
only accepted to create those who were his descendants of blood and who would
inherit their properties. For this, it was necessary that women had sexual relation-
ship exclusively with just one man, and to ensure that it should be delimited the
possibilities of encounters between women and men, ensuring that these meetings
took place only with the one with whom the woman would join to form a family.

V. L. P. Sant’Ana ()
Universidade Estadual de Maringá (UEM), Maringá, PR, Brazil
Instituto Maringaense de Psicologia Analítico Comportamental (IMPAC),
Maringá, PR, Brazil
D. B. de Deus
Pontifícia Universidade Católica do Paraná (PUC-PR), Maringá, PR, Brazil
Centro Universitário Cidade Verde (UniFCV), Maringá, PR, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 243
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_16
244 V. L. P. Sant’Ana and D. B. de Deus

From now on, women become first father’s property and then husband’s property,
the rules about gender roles are expanding and becoming “natural and/or biologi-
cal” social norms (Ariès, 1986), whose aim was to limit as much as possible the
social mobility of women, making their operating spaces always controlled by a
man and restricted to home limits.
It is presumed that, in general, rules formulated in relation to women started
from the assumption that the primary duty and mission of their existence was to
procreate and care for their offspring, the man, and the house, while the man’s role
would be to provide financial support for the family and to dictate the rules that
everyone should follow. Such family and social organization began to be openly
questioned only after the second half of the twentieth century and several actions
and movements took place to make some changes in the female role.
Among the factors that decisively contributed to female emancipation, it can be
mentioned industrialization, the departure of men to war, the counterculture move-
ment of the 1960s, the discovery and commercialization of the contraceptive pill
(Sant’Ana, 1995). Such factors led to a major change in the customs and morality of
that period.
Although the 1960s was a period of liberalization of customs and changes in
women’s social and moral behavior, there was still a strong social component to
impel women to return or remain in maternal and domestic functions: the attribution
of a disorganization and the dismantling of the family with the departure of women
from domestic boundaries. Feminist movements had to act since long before coun-
terculture movements for these changes to solidify and generate changes in the rules
that prescribed which behaviors should be emitted by women, with the initial mile-
stone being women’s struggle for the right to vote.
This struggle, called the suffragist movement, began timidly in the USA at the
turn of the seventeenth century to the eighteenth century and exploded as an orga-
nized movement in the nineteenth century, culminating in August 1920, with the
approval of an amendment to the Constitution that granted everyone the right to
vote, regardless of race or sex.
In Europe, two events brought about profound changes in the structure of society.
The French Revolution (1789) and the Industrial Revolution (1848) triggered a
period of great material, intellectual, and social growth for the entire world popula-
tion (Hosbawm, 2009). In the light of these revolutions, especially the French
Revolution, the feminist movement in Europe was born. Initially, the main demands
of the feminist movement were based on universal suffrage, divorce, education, and
work. In a microstructural sense, the feminist movement gave visibility to the phe-
nomenon of violence based on articulated actions with women in situations of vio-
lence (Teles, 2007).
Feminist ideas and women’s rights movements reached Brazilian women. The
struggle for women’s rights in Brazil can be divided into two major phases: the suf-
fragist movement and the inclusion of women in the labor market as a result of the
second world war (Alves, 1980). In addition to these, many minor movements
occurred both daily and in the political and social scenarios, which enabled the
struggle for the right to vote (Karawejczyk, 2013), which culminated, in 1927, in
16 Drugs Use in Romantic Relationship and Violence Against Women 245

Rio Grande do Norte state, in the institution of the female vote and, finally, in 1932,
this right was extended to all women in Brazil. Regarding the inclusion of women
in the labor market, it is important to highlight, in Brazil, in addition to the post-war
scenario, the Constitution of the 1930s in which labor rights were instituted for
Brazilian women (Guiraldelli, 2007).
The institution of women’s right to vote, as well as their insertion at the labor
market can be seen as historical and political conquests, however, the acquisition of
some rights and the exercise of female citizenship cannot be considered to have
been accompanied by behavioral changes in the male population about how to treat
and perceive women. There was a strong division between what it was like to be a
woman “to get married” and to be a woman “to have fun”, the latter should not be
considered worthy of respect, which meant, ultimately, that she would not be “hon-
ored” with a husband’s last name. The cultural practice of men as provider and head
of the family was also maintained so that division between these types of women
remained active.
The woman legally needed her husband’s permission to perform various civil
acts and even to decide on a sterilization to avoid further children. Furthermore, the
man was allowed a much freer life and without those many restrictions, as long as
he fulfilled his role as provider and had the authority to give the final say in all rel-
evant decisions of his family. In order to have authority, he was allowed to physi-
cally punish both his children and wife. The intensity of punishment would be
related to the man’s assessment of the seriousness of transgression committed, rang-
ing from the imprisonment of woman in a convent, physical aggression, torture, and
even death. This structure allowed violence against children and women to be seen
as normal and even desirable in order to maintain family hierarchy and obedience.
It can be assumed that the way in which we perceive and evaluate women has
formed a cultural bias in which assaulting, raping, killing a woman or a girl has
become common and tolerated throughout history in almost all so-called civilized
countries within the most different economic and political regimes.
As an example of such a culture, in Brazil, under the pretext of adultery, the
murder of women was legitimate before the republic. Koerner (2002) shows that
woman’s sexual relationship outside of marriage was considered adultery, which
allowed her husband to kill them both. For man, there was no adultery, but concubi-
nage. Subsequently, the Civil Code of 1916 changed these provisions considering
the adultery of both spouses as the reason for divorce, the only form of legal marital
separation before 1977 when the divorce began to exist in the country. However,
changing the law did not change the century-old custom of killing a woman, whether
she was a wife, lover, partner, girlfriend, concubine, or daughter. At the beginning
of the twentieth century, the Brazilian population began to have a closer contact
with behavior and values of other countries, which began to be confronted with
local patriarchal traditions still in force, although more weakened.
In the 1920s and 1930s, there was an intense movement of women and some sec-
tors of society that denounced the problem of women’s murder. This movement
progressed almost silently and emerged in the 1970s with the murder of Minas
Gerais columnist Ângela Diniz, the victim of her boyfriend who did not accept
246 V. L. P. Sant’Ana and D. B. de Deus

separation. News reports at the time describe the murderer’s defense attorney’s sur-
prise at the social outcry for him to be convicted.
The demonstrations, in 1970, for the defendant to be convicted had the slogan
“Who loves does not kill”. In that decade, continuing a counterculture movement in
the 1960s, several groups, such as militants against the military dictatorship (insti-
tuted in Brazil after 1964), intellectuals, union members, and workers from different
sectors joined feminists in a daily struggle for rights and better living conditions and
for equality between men and women. Unlike the early decades of the twentieth
century, reports of crimes that were previously hidden and perpetrated against
women became public.
Violence against women was an expression coined by feminist movements a few
decades ago and refers to situations as diverse as physical, financial, moral, sexual,
psychological violence; harassment at work; traffic of women and girls; sex tour-
ism; ethnic and racial violence; violence committed by State (through action or
inaction); the mutilation of female genitals; dowry-related violence and murders;
mass rape in wars and armed conflicts (Brasil, 1995; Grossi, 1995).
In the understanding of violence against women, it is emphasized that this is a
feature of a patriarchal society, marked by sexism, which imposes a role of submis-
sion and social neutrality on women, both in the family context and in the commu-
nity in which they are inserted. These characteristics are currently present both in
the rules that determine women’s socialization as being more linked to the care of
others and in the application of laws that are mostly ignored when referring to wom-
en’s rights. This condition can be understood by the lack of access of women, for a
long time, to a quality formal education directed to scientific thinking and not to the
care of the home and children. By limiting such access, the scope of action of
women in the professional field, which is made up of people who legislate or enforce
laws, becomes limited, forming a barrier that is difficult to overcome. The first
reports of violence against women were initiatives of articulated actions, providing
strategic formulations to face the issue that today is called gender violence. From
this context, violence against women came to be considered a violation of women’s
human rights, moving from the private to the public sphere (Teles, 2007). Thus, we
can mention the Lei Maria da Penha (11.390/06), which was enacted with the objec-
tive of “restraining and preventing gender violence in the domestic, family or in an
intimate relationship of affection” (Brasil, 2006 , p. 11), and which encourages the
creation of public policies for possibilities of confronting violence against women.
Understand what keeps the high frequency of occurrence of aggressions, the
continuity of romantic relationships in this condition, the silence of the victims, as
well as a possible connection between these aggressions with the use of legal and
illegal substances could lead to the elaboration of public policies aimed at both the
general health of population and the mental health of those involved in behavioral
patterns that are harmful to themselves and others. Harmful behaviors are those that,
in a direct or indirect way, prevent or hinder the full development of individual
potentialities and the full exercise of human rights universally defined as inherent to
each person.
16 Drugs Use in Romantic Relationship and Violence Against Women 247

 rug Use in Romantic Relationships and Violence

D
Against Women

Violent or abusive relationship between man and woman goes against the ideal sce-
nario for romantic relationships that, a long time ago, started to be discussed and
sought by many people as the formula for obtaining happiness. Although marriage
based on romantic love is relatively recent in Western cultures, relationships built on
this concept – love – have become the object of fantasy for the vast majority of
people who dream of finding someone to complete them. Such an encounter would
generate, in this fantasy, an internal state of deep peace and joy, in other words, it
would produce happiness in all moments of life.
Considered a traditional practice, especially in romantic relationships, violence
committed by intimate persons is deeply rooted in social life, being perceived, in
most cases, as a normal or natural condition. The victim goes into a cycle of vio-
lence in which her self-esteem and self-confidence are being undermined daily,
leaving her immobilized or unable to react and resort to legal measures that pun-
ishes the aggressor and protects the victim. It can be considered that one of the fac-
tors that contribute to the maintenance of the cycle of violence and non-denunciation
of the aggressor is the woman’s perception of the ineffectiveness of legal measures
in bringing the necessary security to prevent future aggressions.
Although the victim’s affection is mixed with the anger of being beaten, there is
love or what the victim has learned to call it by this concept. Due to the phenomenon
of habituation (Aló & Costa, 2019), even though it is an aversive situation, violence
becomes a necessary element for maintaining the relationship and, however para-
doxical it may seem to other people, violence sustains a significant number of
romantic relationships. Here it is worth remembering that in the face of a situation
that is poor in positive reinforcement stimulation, some stimuli classified as aver-
sive by most people can assume the role of positive reinforcers and maintain behav-
iors that produced them in the past. In addition, the cycle of violence, characterized
by a phase of tension, followed by aggression and, finally, regret and requests for
forgiveness with promises regarding the non-repetition of aggression (honeymoon1)
promotes a mixture of aversive and positive stimuli that, under an intermittent rein-
forcement scheme, can indefinitely maintain the woman’s behavior of remaining in
an abusive or violent relationship.
In addition, it can be assumed that aggressive behavior is reinforced by an escape/
avoidance pattern from the victim that tries, in many ways, to prevent the occur-
rence of a new aggression, either by submitting, or by agreeing with all the aggres-
sor’s requirements. The escape/avoidance responses of the abused woman would act
as positive reinforcers for the aggressor who has his demands promptly met. When
attempting to modify this scenario, with occasional refusals and disagreements, the
victim selects responses in the aggressor with increasingly intense topographies or

1
Honeymoon is an expression used for the interval period in which there is no aggression in the
relationship, which occurs in cycles of violence against women.
248 V. L. P. Sant’Ana and D. B. de Deus

magnitudes, which may reach those that lead to her death. The cultural determinants
that also act strongly in female education make women, since childhood, directed to
roles related to caring for others, to be patient, tolerant, submissive, and non-­
assertive. And boys are educated to behave in the opposite way, which can make
aggressive behavior an acceptable form of conflict resolution.
Among the risk factors that make up the scenario for violence against women,
unemployment, low education, and the use of legal or illegal drugs are also consid-
ered as relevant variables. It is hypothesized that the use of drugs, loving union
between two people, and the permanence in an abusive or violent relationship
adheres to the same rule: the fantasy of finding happiness or well-being outside the
individual (or his behavior), in other words, the fantasy of something or someone
that supplies all needs and desires of the other (the lack of self-reinforced behavior
in the affective situation).
With the appreciation (of social character) of the contingency of lasting happi-
ness and well-being dependent on a loving relationship, it is observed that this is a
cultural practice that makes up the scenario for the constitution of the subjectivity
of individuals, which can be more significant depending on each person’s life his-
tory, including the development of autonomy and self-control (Tourinho, 2009).
According to Skinner (2003), autonomy and self-control are behaviors developed
fundamentally by social interactions, in which certain choices (changes in environ-
mental variables made by individual who behaves) outline the responses that will be
emitted, of autonomy and/or self-control, such as, for example, in staying (or not) in
a loving relationship.
Given that autonomy and self-control are related to cultural practices (Tourinho,
2009) of romantic relationships, another explanation, also of a social character,
would be a correlation between drug use and cases of violence. Regarding the use
of licit or illicit drugs, in addition to being a risk factor, there is in the common
sense, the perception that their use would lead or trigger male aggression against
women. The understanding of behaviors that have guiding rules happens from a
verbal community in which a speaker and a listener are interacting, in other words,
a person or group that issues a rule and another that follows (or not) this rule (Matos,
1969). It is observed that in Brazilian culture, until recently, the use of legal drugs
was an attenuator to reduce social and legal responsibility of behaviors practiced
under its effect.
Therefore, within the social context in which there are rules that determine when
the use of drugs would be responsible for aggressive action, the individual under its
effect would tend to commit violent acts more frequently than in the absence of
these substances since he would not be responsible for the violent behavior, but the
drug. It would seem, therefore, that aggression would be more under the rule of how
he could behave under influence of drugs than the actual effects of the drug used.
The use of substances that modify the functioning of the psyche seems to have
been present in the most varied periods of human evolution, both with regard to a
religious character and to an escape pattern from the daily difficulties encountered
by people from most diverse social classes, educational level, and cultural model. It
can be seen that for each type of use there are specific rules dictating how they
16 Drugs Use in Romantic Relationship and Violence Against Women 249

would work in that context. The use of drugs, in this case, supports the possibility
of justification for violence, which also corroborates that the victim remains in the
relationship, since the partner is under the effect of substances and not in his “nor-
mal” state, in a movement that individualizes the problem, disregarding cultural
characteristics, such as the establishment of rules that make up its context.
Several studies search for a causal relationship between the use of legal and ille-
gal drugs and the increase in violence in general and, specifically, domestic violence
(Amaral, Vasconcelos, Sá, Silva, & Macena, 2016; Barros et al., 2016; Fonseca
et al., 2009; Leite et al., 2017; Minayo & Deslandes, 1998; Rabello & Junior, 2007;
Vieira et al., 2008; Vieira et al., 2014). According to Minayo and Delandes (1998),
the complexity in understanding the relationship between violence and drugs lies in
the difficulty of measuring and/or verifying behaviors or effects from the use of
legal/illegal substances. Still, according to these authors, the correlation of fre-
quency between violence and drugs varies depending on the measurement between
serious events or events that become worse on these occasions.
Abuse of drugs by the partner seems to make women even more vulnerable in
situations of violence in marital and family relationships by the justification estab-
lished by the woman that the aggressor is not a violent person but is behaving under
the effect of something stronger than him, the drug. Although alcohol abuse and
violence are approached as a causal relation, it is noteworthy that such a relation is
not confirmed since drugs can be one of the factors that contribute to violence, but
not exclusively, as already stated when discussing the control of rules on violent
behavior presented after drug use. It is also observed that social consequences, even
if delayed, are relevant to the maintenance of certain cultural practices and some
social contingencies occur so that the individual can deal with the world based on
relational networks (Das Neves, 2017).
Drug abuse and violent behavior is a complex relation involving several aspects,
such as types of positive reinforcers involved in the relation, magnitude of these
reinforcers, reinforcement scheme under which violence was initiated and main-
tained, and the escape/avoidance behavior of those involved in the violent episode,
among other aspects. When we understand that the use of alcohol, as well as other
drugs, and episodes of violent behavior do not have a clearly defined interaction, we
do not know the direct and/or indirect influences of environment; the individual
characteristics of users of alcohol and other drugs; the prevalence and the precise
correlations between such influences (Amaral et al., 2016; Barros et al., 2016;
Fonseca, et al., 2009; Rabello & Junior, 2007), it is important to research and dis-
cuss results that assess the complexity of the context, the social dynamics, the cul-
tural norms historically constructed (such as gender issue), factors of development
and individuality, and from that, to institute public policies that meet the needs of
those involved.
It is considered that behaviors and roles culturally delegated to men and women
prevent those from learning to demonstrate their weaknesses, insecurities, and feel-
ings, while girls learn, from an early age, to behave in terms of submission and
agreement. In Western society, during the initial periods of schooling, boys are
expected to be more object-oriented, more competent for physical activities, more
250 V. L. P. Sant’Ana and D. B. de Deus

aggressive, to be achievement-oriented, independent, and dominant in relation to

girls for whom the expectations are contrary to those of boys (Sant’Ana, 1995). One
of the effects of this socializing process would be that many men have problems in
relating to their partner, their children, and the community they belong to. The
socialization of boys also points to the use of alcohol as a pattern rooted in social
and cultural contexts considered acceptable for relating such use to disinhibition
and improvement of mood and also as a symbol of virility and physical resistance
in men. In addition, it can increase the concentration on immediate events by reduc-
ing awareness of future events or those that are distant in time, producing effects
that reduce social stress in men. As a mood enhancer, this substance can also
increase existing feelings of anger and frustration, changing men’s perceptions of
women, making these an immediate and vulnerable target.
In a context in which the aggression response occurs, while the individual is
under influence of drugs, this response can be maintained, for example, by the vic-
tim’s self-silencing (non-denunciation), which brings evidence of the power that
this man has over this woman, as it is culturally perpetuated as the hegemonic pat-
tern. Some of these situations of violence happen at home with the couple’s children
present, or even children of other relationships (Souza & Da Ros, 2006). The repeti-
tion of similar situations produces, in the long term, behaviors called low self-­
confidence and low self-esteem, which would provide a favorable condition for
violence to be repeated without making complaints, which would be the first step
toward subsequent legal protective measures. The absence of denunciation or non-­
provocation of marital separation by women is, in most cases, due to financial
dependence, especially thinking about the care of children, the fear of the partner
suffering some type of punishment, the hope that the partner will change, the living
with fear – something even worse can happen with the denunciation or separation –
as well as the time of life together and the annulment of women in this relationship
(Souza & Da Ros, 2006). Such facts help us to understand woman’s difficulty in
breaking the violent relationship.
It is also worth reflecting on the degree of aversiveness of certain stimuli, because
the functionality of this stimulus is initially expressed by weakening a response
(Skinner, 2003); however, it is possible to discuss a binary relationship (Hunziker,
2017) in which certain situations at the same time that they are aversive also contain
reinforcing aspects. The woman’s behavior of maintaining a relationship in which
she suffers violence can be understood by the fact that aggression has aversive char-
acteristics – which would weaken probabilities of the relationship continuing –
while there are positively reinforcing aspects, such as having a partner (on whom
the woman depends financially, has minor children, religious rules or avoidance of
social judgments, etc.) which increases the probability of emitting behaviors that
maintain a violent or abusive relationship.
The analyses presented so far help us to understand situations of violence, both
from the perspective of woman’s permanence in this relationship, as well as from
the maintenance of aggressive acts by the man, which leads us to reflect on the
importance of public policy projects that favor the possibility of specialized
16 Drugs Use in Romantic Relationship and Violence Against Women 251

assistance to female public, also considering the importance of projects that involve
these men for effective changes.
To recognize the social and assistance needs of women in situations of violence,
it is essential to understand the relationships they establish with partners, children,
family members and the care demands arising from these relationships, such as
protection of children and actions to combat abusive use of alcohol and other drugs
by partners.
The woman’s desire to break the cycle of violence after the denunciation was
made or to abandon her life to end the suffering can be attributed to the intensity and
perception of the violence suffered, which leads to a lowered self-esteem, the
destruction of self-confidence, and an intense psychic suffering.
Changes in the population’s health needs, as well as the history of use of alcohol
and other drugs, are considered to require implementation of new services and pro-
fessional performance strategies, in addition to a strictly biological approach,
emphasizing also social aspects. It is necessary to incorporate the perspective that
the mental health of women and their partners is determined by issues of gender,
socioeconomic and cultural conditions, and general health practices and habits.

Clinical Case Report

This work, carried out through an extension project, was developed at the Clinical
School of Psychology of the State University of Maringá (UEM) and had 200 par-
ticipants/year, including men, women, and children involved in violent relationships
or legally denounced for conjugal aggression. The consultations took place in indi-
vidual and group service rooms, which are equipped with chairs, table, stereo, mul-
timedia device, and laptop. For the development of this work, a partnership was
established with SETI-PR (General Superintendence of Science, Technology and
Higher Education), fifth Court of Women, Childhood and Youth and the Municipal
Secretary of Women and aimed to offer women some instruments that would enable
them to fight for the consolidation of their rights, including gender as a guiding
category for local public policies; to aggressors, the service aimed to enable them to
acquire behavioral patterns to resolve conflicts that were incompatible with the
aggression. The service was extended to all members participating in family life2
exposed to the situation of domestic violence.
In order to achieve the objective, the profile of both aggressors and victims of
violence was outlined (data from 2018) and then psychological assistance was
offered to women in situations of violence, in order to change some factors that
make them more vulnerable to aggression, such as staying physically close to the
aggressor, not reporting the aggression suffered, having a pattern of submissive
behavior, among others, and assisting male aggressors in order to remodel violent

2
This text does not address the work done with other family members exposed to violence.
252 V. L. P. Sant’Ana and D. B. de Deus

behavior patterns. An important factor in the aggressors’ permanence in psycho-

logical care was the exchange of alternative sentences of community services for the
frequency of those sentenced to weekly sessions. Although it is a coercive measure,
it was seen, by aggressors, as an advantageous exchange and, if it did not guarantee
unconditional adherence to the proposed activities, it enabled the knowledge and
recognition of aggression as illegal and subject to legal sanctions, since in first ses-
sions their assaults were assessed by them as a right over women and not as a crime.
Among the data obtained on the behavior of the aggressors, it is found that, of the
21 participating men, the majority (82.1%) uses alcohol or other drugs during the
week and, of these, the majority (76%) is more violent when they are under influ-
ence of alcohol or other drugs (according to the victims’ reports). A small portion
(10.9%) would be willing to undergo treatment for alcohol and other drug addiction.
This result seems to confirm the rule that emission of aggressive behavior is influ-
enced by alcohol. We cannot state, however, whether the emission of the aggressive
behavior is due to the lowering of the assessment of current and future contingen-
cies or to other variables such as the perception of women as vulnerable and
submissive.
Of the 21 women in situations of violence who were attended, the majority
sought the women’s police station within 48 hours after the fact (77.2%); previously
separated from the perpetrator of violence (74.3%); previously registered police
occurrences (50.7%); they feel they are an isolated person (45.6%) and attribute this
feeling to the violence suffered (48.1%); already had psychological or psychiatric
treatment prior to that provided by the project (29.8%).
The service with men occurred in a standardized way, constituting a service pro-
tocol. In total, twelve weekly sessions of fifty minutes each were conducted for a
period of three months. The service was divided into two phases: the first phase
consisting of four individual sessions, and the second phase, with eight sessions in
groups composed of up to 10 participants. The sessions were conducted by a psy-
chologist and a student, both members of the extension project and guided by the
first author of this chapter.
In the first phase, we sought to create a therapeutic bond and collect the client’s
life and love relationship histories. In the second phase, eight group sessions lasting
1 h and 30 min each were held, coordinated by one of the project professionals with
experience in assisting men who committed domestic or intrafamily violence and an
intern, and aimed to create conditions for the occurrence and functional analysis of
behaviors that are configured as requirements for an adequate and non-violent social
performance (Del Prette & Del Prette, 2003; Villa & Del Prette, 2012), these behav-
iors being: (a) self-knowledge (emotional expressiveness), (b) self-control, (c)
empathy, and (d) assertiveness. Each of the skills-themes was approached in two
meetings with a theoretical discussion about the target concept or skill and practical
activities: identification training or contextual proposition for emission of the
behavior or skill.
Women were attended in at least 12 individual sessions and the topics covered
were about types of violence suffered, feelings that emerged before, during, and
after the episodes of violence, behaviors presented in each episode of violence and
16 Drugs Use in Romantic Relationship and Violence Against Women 253

in the intervals between each episode, and the way of perceiving both the aggres-
sions, and the social consequences they received, in other words, we seek a func-
tional analysis of women’s behavior and the search for viable alternatives to interrupt
the cycle of violence suffered by them. Therapists also discussed any topics that
these women considered relevant whether or not they were linked to situations of
domestic violence.
In the context of Pro-Mulher, it was possible to verify that the majority of abusive
men consumed alcohol and/or other drugs and this, as previous studies already
describe, seems to have some relation with violent act, although this fact cannot be
considered as the variable more relevant or even the one that would trigger the
aggression. Considering that this data may show a relationship between drug use
and violence in a love relationship, it is necessary to expand studies to understand
and analyze culture and cultural practices as a determining part of situations of
violence.
With the conclusion of the proposed work, it was possible to verify that the
women attended had a higher frequency of assertive verbalizations about their rights
and a greater ability to not expose themselves to risk situations by emitting behav-
iors different from those of submission and agreement initially presented and that
culminated in aggression by their partners. Men demonstrated a greater ability to
discriminate and report feelings and emotions, presented a greater number of ver-
balizations about being able to control themselves by emitting behaviors incompat-
ible with those of aggression and demonstrating verbalizations of understanding
and empathy with their women. It was not possible to discriminate if the report of
self-control was due to the development of empathy with victims or a greater sensi-
tivity to contingencies, in other words, an avoidance of legal punishments.

Final Considerations

The central discussion in this chapter was about violence against women in a roman-
tic relationship, as well as a possible correlation between violence and the use of
legal and illegal drugs. Violence against women has a multi-determined explana-
tion, the cultural context, in its cultural practices, directly interferes with the main-
tenance of these relationships, silencing women in abusive or violent romantic
relationships. From these cultural practices, we can point out possible rules that
relate drug use and violence. Although there is an understanding that drug use is a
risk factor for cases of domestic violence, it is not possible to establish such a cor-
relation as a constant.
The woman’s desire to break the cycle of violence (from denunciation and/or
separation) seems to be related to the intensity and perception of the violence suf-
fered, which would generate a pattern of behaviors called lowered self-esteem and
self-confidence. This pattern would be acquired during the constitution of subjectiv-
ity of each woman in particular and would provide the prerequisites for emission of
254 V. L. P. Sant’Ana and D. B. de Deus

escape and avoidance behaviors effective to eliminate or minimize the possibility of

being assaulted.
Data obtained from the population that participated in the Pro-Mulher program
indicate that aggression of men against women can be explained by culturally trans-
mitted behavioral patterns, among which are the incentive to drug use, especially
licit ones like alcohol, that would generate, for both, women and men, the construc-
tion of an image about aggression, as if this would only have occurred because the
aggressor was under influence of drug, in other words, it would not be a constant
behavioral pattern, but an exception for being “out of mind” or “high”. Thus, there
was a devaluation of aggression as a learned and maintained behavior due to its
consequences in conflict resolution. During the sessions with the aggressor men, it
was possible to perceive verbalizations that denoted possession of man over the
woman (for example, “it is a lie that I beat women ... I beat only mine”), and that she
must be punished when she violates rules imposed by man (“and I hit because she
disrespected me”). The work developed proved to be effective in reducing submis-
sive and risky behaviors among women victims of aggression and in increasing
defense and assertive exercise of their rights. For men, the behaviors of aggression
and non-compliance with protective measures had their frequencies reduced when
compared to events described by them in the initial sessions, and verbalizations with
negative content about women assaulted by them had a decrease in intensity and
frequency when compared with those of initial sessions.

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Chapter 17
Challenges of Clinical Behavior Analysis
in Legal Substance Use: Alcohol
and Tobacco

Fernanda Calixto

Introduction

According to the World Health Organization (2018), five million people die due to
smoking-related factors worldwide. Approximately 50 diseases – including cancer,
high blood pressure, emphysema, and stroke – relate to the consumption of ciga-
rettes, cigars, and pipes (i.e., tobacco products). Such data place smoking as the
world’s leading preventable cause of death. WHO data on alcohol consumption are
also alarming. As of January 2019, the organization reported that harmful use of
alcohol is one of the risk factors with the greatest impact on morbidity and mortality
worldwide, associated with 3 million deaths in 2016. Of alcohol-related deaths:
28% are related to those caused by traffic accidents, self-harm, and interpersonal
violence; 21% are due to digestive disorders; 19% to cardiovascular diseases; and
the remainder are due to infectious diseases, cancer, mental disorders, and other
health conditions.
In a national context, according to an estimate by the Brazilian Ministry of
Health, 200.000 people die annually because of smoking and this number is likely
to remain steady if the prevalence of smokers does not decrease (Ministry of Health/
National Cancer Institute – INCA, 2019a, b). Regarding alcohol consumption in
Brazil, the Ministry of Health announced in 2018 through the Global Report on
Alcohol and Health1 that approximately 2.3 million people met the criteria for alco-
hol dependence within the 12 months preceding data collection. The survey – which

1
Relatório Global sobre Álcool e Saúde: https://cisa.org.br/index.php/pesquisa/dados-oficiais/
artigo/item/71-relatorio-global-sobre-alcool-e-saude-2018

F. Calixto ()
Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
Centro Paradigma de Ciências e Tecnologia do Comportamento, São Paulo, SP, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 257
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2_17
258 F. Calixto

heard about 17,000 people aged between 12 and 65 across Brazil between May and
October 2015 – is considered one of the most thorough for its scope.
Due to their deleterious effects on health, tobacco and alcohol consumption have
become a target of public policies and interventions offered by Brazil’s healthcare
network. The National Tobacco Control Program,2 for example, has been offered by
the country’s Unified Health System3 since the 1980s. Also, in 2007, a decree
approved the National Policy on Alcohol4 that provides measures to reduce its mis-
use. Anti-smoking laws (Law No. 9294) were also adopted in Brazil aiming to
restrict the use and advertising of tobacco products in public places and the media.
In addition, Brazilian legislative institutions have enacted laws that restrict the use
of alcohol before driving and the publications of advertisements for alcoholic bever-
ages (Brasil, 1996; Article 306 of Law No. 9.503 and Law No. 9.294). These mea-
sures show that regulating legal psychoactive substances has been a common
governmental measure to control their excessive consumption.
Although these laws and measures aim to regulate alcohol and tobacco (by not
allowing smoking in closed public spaces or driving under the influence of alcohol,
for instance), the consumption of such substances is considered legal both in
national and international contexts. Cigarettes have not been advertised on Brazilian
television since 2000, although beer and other alcoholic products are still com-
monly advertised in the mainstream media.
Alcohol and tobacco are psychoactive substances that have been present in dif-
ferent societies for decades. Elevated consumption rates are related to their addic-
tive effects as well as cultural practices. In general, the power of psychoactive
substances resides in their activation of the brain’s reward system – i.e., their use
causes immediate pleasure – commonly resulting in physical and psychological
dependence. Physical dependence can be observed through body changes in the
absence of the substance. As an example, we can cite withdrawal crises in which
several extremely unpleasant symptoms may be present depending on the drug
used. In tobacco withdrawal, the individual commonly experiences nausea, anxiety,
and headaches whereas in alcohol, they experience tachycardia, sweating, and trem-
ors, among others. Psychological dependence is observed in cases in which the
individual starts presenting habits to ensure the consumption of the substance. In
cases of addiction, users commonly direct all their money to using the substance.
Their social circles also become predominantly formed by both friends and acquain-
tances who are users and people who are part of substance-use-related
environments.
For causing great direct harm to an individual’s health, addiction to psychoactive
substances (legal and illegal) is the target of analysis and intervention in clinical
behavior analysis. According to behavioral-analytic principles, the pattern under-
stood as “chemical dependence” is learned and governed by the same principles and

2
Programa Nacional de Controle do Tabagismo.
3
Sistema Único de Saúde (SUS).
4
Política Nacional sobre o Álcool.
17 Challenges of Clinical Behavior Analysis in Legal Substance Use: Alcohol… 259

laws of any behavior (Higgins et al., 1991). Behavioral-analytic therapists thus hold
the challenge of identifying from the client’s history how such a complex consump-
tion pattern emerged and what variables account for its maintenance.
From the same perspective, smoking and alcohol cessation is unlikely to occur in
cases of addiction as consumption is maintained by powerful immediate reinforcers
(Rachlin, 2000). We say that a consequence is reinforcing when it increases the
probability of evoking a certain class of responses. Regarding the consumption of
psychoactive substances, an immediate effect is the physiological changes that the
substance causes in the body with the activation of the reward mechanism and dopa-
mine release (Robbins & Everitt, 1996). Such change may suffice to increase the
probability of evoking a whole chain of responses that result in access to the sub-
stance. In addition, other consequences may control the same responses. Social
reinforcers – such as attention and companionship during consumption – can be
functionally related to both drinking and smoking. Also, negative reinforcers gener-
ally relate functionally to consumption since smoking can eliminate or delay con-
tact with aversive events. For example, users commonly report that drinking reduces
anxiety and stress, and increased consumption generally occurs in situations known
to be difficult such as family or work-related problems.
We consider addiction a state in which consumption occurs to avoid negative
organic effects in the absence of the substance (McLellan et al., 2000). In these
cases, physical discomfort such as nausea, body aches, shaking, among others are
regarded as craving states when individuals are abstinent. In sum, for every user of
psychoactive substances, either a specific or a group of consequences may be main-
taining the consumption chain.
A special aspect of alcohol and tobacco – in comparison to other substances such
as marijuana and cocaine – is the fact that they are considered legal in Brazil, which
influences consumption patterns as well as the possibilities of intervention. This
chapter addresses specific challenges observed in clinical behavior analysis inter-
ventions regarding the use of legal substances. Due to their overwhelming effects on
users’ health, alcohol and tobacco constitute the focus of analysis. The following
topics will be discussed: (1) Social acceptance; (2) Response Cost in Obtaining and
Consuming; and (3) Diverse Pairings and Functions. Lastly, as examples of effec-
tive behavioral-analytic interventions, I present one study focused on tobacco and
one on alcohol reduction.

Public Opinion – Social Acceptance

In 2017, Venture conducted a survey on the public opinion and morale of legal and
illegal drug use in Brazil. Results showed an adverse public opinion in relation to
consumption and consumers (41% in feelings of disgust or hatred plus dislike) and
the vast majority were favorable to maintaining the prohibition of commercializa-
tion and consumption of crack (94%), cocaine (94%), and marijuana (80%). Despite
not directly comparing public opinion between licit and illicit drugs, Venture’s
260 F. Calixto

(2017) findings reveal that the consumption of the latter is potentially followed by
social punishment since the theme is vastly judged using negative adjectives.
Considering that a group feels repulsion, hatred, or animosity toward a habit (in
this case, using illicit drugs) we can say that such consumption is likely to be fol-
lowed by aversive social contingencies. For example, a mother may threaten to
remove reinforcers after discovering or suspecting that her daughter is using mari-
juana, or even curtailing her freedom by demanding her hospitalization. Regarding
the consumption of legal substances, although there are indications of a negative
public opinion, results do not show manifestations in favor of its prohibition. This
may show that social punishment for the consumption of legal substances, when
present, occurs in smaller magnitude compared to illegal ones. For example, despite
the enormous harm caused by tobacco to the health of smokers, no institution spe-
cializes in hospitalization for compulsive use of cigarettes; whereas, in Brazil, there
are legally supported clinics that perform involuntary hospitalization for marijuana
addicts.
Opinions can be understood as verbal descriptions of an event. When they point
to causal functional relations such as “cocaine should be prohibited”, “whoever uses
it must be hospitalized or arrested” we are referring to a verbal description of a
contingency, aka a rule (Skinner, 1953). In this case, Venture’s (2017) findings show
that verbal descriptions (i.e., rules) regarding the consumption of illicit substances
in Brazil often specify aversive consequences. Considering that rules control both
verbal and non-verbal behavior (Matos, 2001), comparatively, the use of licit sub-
stances such as alcohol and tobacco is likely to be accompanied by verbal descrip-
tions that specify less aversive consequences.
We must note that the aversiveness of an event is defined by both its historical
and present consequences, as well as specific and individual ones (Sidman, 1995).
Verbal descriptions – such as “cocaine users must be arrested” –are likely to be inef-
fective in differentially affecting users’ behaviors while having opposite effects in
others. On the other hand, Venture’s (2017) findings help us differentially under-
stand social judgment toward users of both licit and illicit drugs.
The social acceptance of substances such as alcohol and tobacco consists of a
challenge to interventions focused on the reduction of excessive consumption since
many cases result in powerful social reinforcers. Reports such as “I knew I would
feel miserable the next day, but I didn’t want to be the only one not drinking”, “I
tried to pace myself, but everybody started talking about the cocktails in the menu”,
“they offered me beer about six times, I declined five of them…”, “I want to stop,
but everybody in the office smokes after lunch and gossip about the people in the
division” are common in the clinical setting and reveal that inadequate behaviors –
for being either excessive or harmful – can be acceptable and even encouraged
depending on the social context.
17 Challenges of Clinical Behavior Analysis in Legal Substance Use: Alcohol… 261

Response Effort in Obtaining and Consuming

What is common about the consumption of alcohol and tobacco is how easily they
can be accessed and purchased. In Brazil, tobacco products are found in tobacco
shops, service stations, bakeries, and grocery stores. Given that cigarettes are con-
sumed in social contexts, another facilitator is the possibility of asking a smoker for
a cigarette. Alcohol can be accessed just as (if not more) easily. Alcoholic beverages
are sold in bars, restaurants, stores, and service stations, among other establish-
ments, in addition to being present in various social gatherings such as birthdays
and celebrations. Illicit substances, however, tend to be sold with more discretion
(the dealer quietly stands at a specific place in the club) and in illegal places (“bocas
de fumo”, for instance, which are earmarked places for drug dealing and use in
Brazil).
Easy access to licit substances favors a lower response effort, that is, I can get
whatever substance I want without major physical or financial efforts. Response
cost is usually referred to as the physical, financial, and temporal requirements of a
response to enable access to its reinforcers (Alling & Poling, 1995). Having the
substance available for purchase in the local market around the corner configures a
smaller response cost when compared to having to go to a remote boca de fumo, for
instance.
According to Weiner (1962), the response effort affects the likelihood of a behav-
ior, so it must be understood as a variable of its function. Experimental behavior
analysis studies with humans and non-humans (Alling & Poling, 1995; Luce et al.,
1981; Pietras & Hackenberg, 2005) showed that, depending on the response cost,
the probability of occurrence of behaviors changes.
Easy access to legal substances is a recurring theme in the definition of policies
and, despite maintaining alcohol and tobacco as legal substances, many decisions
aim to make the access more difficult, either by restricting authorized retail places,
or by increasing taxes and, by extension, the end price of the product. Countries
such as Brazil, the United States, and England pose restrictions on authorized loca-
tions of tobacco consumption. In California, for example, smoking is prohibited
even in several beaches and parks. Regarding costs, a survey carried out in 2018 by
Forbes reported that, while a pack costs an average of 2.22 USD in Brazil, it can
cost up to 20,14 USD in Australia – country that used taxation as a restriction mea-
sure. Recent data indicate that, although price increase may lower the number of
smokers (Forbes, 2018), the measure is controversial. Additional data show that, as
taxes rise, the purchase of taxed products decreases while black market products
become more popular (Exame, 2019). For this reason, Brazil’s Ministry of Justice
announced in 2019 the possibility of reducing cigarette-related taxes to contain
smuggling (O Globo, 2019).
Increasing taxes and restricting consumption places of alcohol, however, has
been discussed and adopted very scarcely – mainly occurring for religious reasons.
India and the United Arab Emirates, for example, have laws to prevent the com-
merce and consumption of alcoholic drinks, which raises the price of products and
262 F. Calixto

narrows their consumption to touristic contexts only. It is important to mention that

the response cost involved in consuming a psychoactive substance is directly related
to its social acceptance. Substances with lesser social acceptance – for religious
reasons, for example – tend to be related to a higher response cost of obtention.
Such response cost thus configures a challenge to interventions focused on
reducing excessive consumption of alcohol and tobacco, as these products can be
accessed with little to no effort. Reports such as “it’s hard to avoid, because I can
buy it right next to the office”, “I didn’t even have cigarettes on me, but I ended up
asking for one in the club”, “I felt more like drinking after I saw everyone else doing
so” are extremely common in session. Low response cost implies that consumption
can easily happen in multiple contexts. Social acceptance also increases the likeli-
hood of drinking in multiple places, in the presence of various people. Given that
substance consumption involves respondent and operant processes, an additional
challenge – addressed in the next topic – refers to the multiple functions it can have
in the life of an individual.

Multiple Pairing and Functions

By asking the client to self-monitor cigarette consumption to understand its control-

ling variables, we commonly hear reports such as “I smoke when I arrive at work, I
smoke another cigarette at break, one before lunch, another one with coffee after I
eat … I smoke when I get home after work and at college before class…”. In these
cases, smoking is clearly related to multiple contexts. Therefore, different events –
constantly present in the client’s life – are likely to evoke smoking. When analyzing
the consequences of smoking, it is not uncommon to find that this behavior has
multiple functions.
Control by social reinforcement can be illustrated by the following reports “I
asked the guy I found cute for a cigarette at the party yesterday”, “I always smoke
at break between classes with my classmates”, “if you want to know what’s going
on at the company, just join the people smoking outside”. Regarding control of tasks
by negative reinforcement we find the following reports: “I need a smoke before I
start”, “when I finish a document, I have a smoke to gather the courage to continue
working on the spreadsheets”. Also, behaviors can be controlled by avoidance or
escape of covert events, which can be identified in reports such as “I was too ner-
vous, so I had a smoke and I managed to take a breath and relax” and “I already had
a headache for staying 5 hours without smoking”. Regarding alcohol consumption,
drinking is also extremely common in multiple contexts (e.g., at friends’ houses,
bars, restaurants, celebrations, among others) with multiple functions (e.g., social
reinforcement of friends, escape, and avoidance of aversive events).
All reports mentioned previously refer to a single clinical case and they show
that this client (a 28-year-old male) habitually smoked at work, college, and home,
either alone or in the presence of friends. Regarding the consequences that control
smoking, we have both social as well as negative reinforcement (avoidance of tasks,
17 Challenges of Clinical Behavior Analysis in Legal Substance Use: Alcohol… 263

covert states, and nicotine craving). In clinical practice, cases such as the previous
one are recurring and they show that therapists must thoroughly analyze variables
that may have a function on that client’s smoking and drinking habits.
Comparatively, when we analyze environmental variables involved in consum-
ing illegal substances (e.g., cocaine), due to an increased chance of punishment and
high response costs, such consumption is likely to be related to specific contexts
(e.g., the client reports having a single cocaine dealer and generally uses it when
alone or in the presence of other user friends). However, the controlling variables of
any behavior are different depending on the learning history. Therefore, users may
do cocaine in multiple contexts, with various functions, just as alcohol users may
have single, specific controlling variables. However, due to social acceptance and
large availability, licit substances are more likely to be consumed with various func-
tions – which consists of an additional challenge while defining effective interven-
tion plans.

Examples of Clinical Behavior Analysis Interventions

In relation to tobacco, the study by Cole and Bonem (2000) demonstrates a proce-
dure based on a functional analysis of smoking. They propose a procedure of grad-
ual nicotine decrease that aims at reducing the aversiveness of substance withdrawal.
Two college students participated in the study: Sue (18 years old) and Tom (21),
both smokers. The study was held in four 45-minute group therapy sessions and
used a multiple component experimental design. In Phase 1 (baseline), participants
provided carbon-monoxide (CO) measures and self-monitored smoking rates –
which continued to be measured across the study. In Phase 2, participants received
tools to register events related to smoking aiming at analyzing it functionally. In
Phase 3, the interval between two smoking events progressively increased. In Phase
4, participants were instructed to implement self-management strategies according
to the functional analysis in Phase 2, which involved changing antecedent situations
functionally related to smoking, as well as the promotion of either alternative or
concurrent skills. At the end of Phase 4, participants were re-exposed to baseline
conditions. Follow-up measures were collected 14 days and 6 months after the con-
clusion of the study.
Sue presented a baseline of 6.5 cigarettes a day. She was able to lower daily ciga-
rette consumption to 3.5 during Phases 2 and 3 and maintain it in Phase 4 and base-
line regression. CO measures remained close to behavioral ones, except in Phase
3 in which CO measures were higher. Tom smoked 13 cigarettes a day during base-
line, progressively lowered to 2 during Phases 2, 3, and 4, maintained Phase 3 per-
formance on baseline regression, but returned to Phase 1 rates during follow-up.
Tom’s CO measures remained close to behavioral ones across the study. Results
showed that the intervention can be considered effective for Sue in lowering by 70%
and maintaining low smoking rates at follow up whereas Tom’s smoking rates low-
ered by 60% during the study and failed to remain low during baseline regression.
264 F. Calixto

Results show the importance of understanding the function of smoking and gradu-
ally lowering nicotine consumption to decrease the likelihood of aversive states
related to withdrawal.
The second study refers to an intervention on Acceptance and Commitment
Therapy (ACT) which consists of a contextual functional approach based on the
Relational Frame, known as a third-wave therapy. The study was conducted by
Thekiso et al. (2015) and aimed to compare the effectiveness of ACT with a stan-
dard treatment in reducing both alcohol dependence and anxiety-depression states.
Participants were 26 patients with alcohol dependence and minimum age of 18
sorted into two groups. The first one consisted of a five-week protocol with core
ACT interventions: Acceptance, Cognitive Diffusion, Being Present, Self as
Context, Values, and Commitment Actions (for details, see Hayes et al., 2008). The
second one received standard treatment which consisted of psychoeducation about
epidemiology, medical complications of alcohol dependence and affective disor-
ders, the interaction between mood and substances, psychotherapy, and pharmaco-
therapy. Dependent variables were scores on the Beck Depression Inventory (BDI),
Beck Anxiety Inventory (BAI), and Obsessive-Compulsive Drinking Scale (OCDS).
Follow-up measures were obtained 3 and 6 months after the study concluded.
Results showed that patients who received ACT interventions scored significantly
lower on BDI and BAI when compared to standard treatment on both follow-up
tests as well as on the first follow-up for OCDS. The authors concluded that the
intervention based on ACT was effective in lowering both drinking and anxiety-­
depression states.

Final Considerations

The present chapter aimed to outline some clinical challenges in interventions for
licit substance dependence – especially alcohol and tobacco. Both substances are
highly consumed worldwide and present multiple deleterious health effects to users.
Behavior analysis and the clinical practice based on its principles help us to func-
tionally understand psychoactive drug consumption behaviors and – especially
regarding alcohol and tobacco – allow us to analyze and raise hypotheses on the
variables involved in their consumption.
Social acceptance of both substances allows us to infer that their consumption is
less intensely punished when compared to illicit substances. Low response costs
involved in obtaining alcohol and tobacco as well as the scientific findings on
response cost allow us to understand why consumption happens in multiple contexts
and functionally relates to multiple events. Control exerted by both positive and
negative reinforcers in various contexts is presented as an additional challenge that
requires a thorough functional analysis prior to defining intervention procedures.
Lastly, both experiments described here point to an effectiveness of interventions
based on behavioral principles as a safe therapeutic pathway focused on lowering
alcohol and tobacco consumption.
17 Challenges of Clinical Behavior Analysis in Legal Substance Use: Alcohol… 265

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Index

A negative thoughts, 150

Abolishing operation (AO), 220 procedural self, 151
Absenteeism, 139 psychological flexibility, 149
Abstinence syndrome, 8, 36, 37, 114 radical behaviorism, 151
Abuse behavior, 207 self process dimensions, 151
Abuse/dependence, 61 substance use, 150
Abusive/violent relationship, 248 values, 151, 153
Accelerated thinking, 150 western culture, 149
Acceptance, 149, 152, 154, 195 Action Scanner, 153–155, 157–158
Acceptance and commitment therapy (ACT), Adaptive denial, 142
118, 264 Addict mind, 140, 141
behavior analysis, 149 Addictive behaviors, 77
committed actions Adolescence, 6
action scanner, 153, 154 Adultery, 245
Likegram, 154–156 Affective indifference, 181
SUD treatments, 156 Aggression response, 250
mental disorders, 147 Aggressions, 246–248
mindfulness, 148 Aggressive behavior, 247, 252
PAS, 148 Aggressiveness, 110
RFT, 149 Aggressor’s behavior, 252
substance dependence treatment, 147 Aggressors’ permanence, 252
SUD treatments, 148 Agonists, 41
treatments, 148 Alcohol, 209, 215
Accumbens nucleus, 213 abstinence, 8, 45
ACT intervention, 119 ACT, 264
ACT Likegram, 155, 158–161 behavior analysis, 264
ACT processes beverages, 261
acceptance, 149, 152 Brazil, 257, 259
cognitive fusion, 150 chronic use, 8
committed actions, 152 CNS, 7
contextual self, 151 combined use, 9
defusion, 149, 150, 152 consumption symptoms, 7
history, reinforcement, 152 deaths, 257
mindfulness, 150 drinking, 262
negative feelings, 150, 152 ethanol, 45

© The Author(s), under exclusive license to Springer Nature 267

Switzerland AG 2021
S. M. Oliani et al. (eds.), Behavior Analysis and Substance Dependence,
https://doi.org/10.1007/978-3-030-75961-2
268 Index

Alcohol (cont.) Consequence Selection Model, 52

health, 258 internal environment, 209
laws and measures, 258 motivational interviewing (see
legal substances, 261 Motivational interviewing (MI))
licit drug, 7 neuroscience, 26, 208, 215
liver, 45 organism vs. environment, 23, 25, 26
neurotransmitter systems, 45 private behaviors, 208
occasional use, 8 psychology, 25, 26
psychoactive substances, 258 public behaviors, 208
risk factors, 257 radical behaviorism, 24, 208
short-and long-term damage, 8 research, 25
social acceptance, 260, 262, 264 science, 25
symptoms, 8 theoretical model, 24, 25
taxes, 261 Watsonian behaviorism, 24
tolerance, 45 Behavioral demolishing operations, 61
verbal descriptions, 260 Behavioral economics, 43
withdrawal, 258 Behavioral functions
Alcohol and cocaine consumption, 170 analysis, 224
Alcohol cessation, 259 decomposition, 225
Alcohol dependence, 117, 227 disturbance, 231–232
Alcoholic beverages, 261 final situation, 237
Alcohol-related deaths, 257 initial situation, 229–230
Alternative rebellion, 142 maintenance stage, 238
Ambivalence, 65, 195 marital relationship contingencies, 219
American Psychological Association narrative sequences, 230
(APA), 147 PAS progression, 219, 220, 225
Amines, 212 responses, 232
Amphetamines, 12, 13 spouse’s involvement, 222
Analytical-behavioral theory, 25 tranformation, 233–234
Anatomophysiology, 212, 213 Behavioral perspective, 62
Anonymous Alcoholics, 222 Behavioral pharmacology, 26, 78
Antagonists, 41 absorption, 40
Antecedent-behavior-consequence model behavior vs. drugs, 43, 44
(A-B-C model), 225 bloodstream, 40
Antecedent context, 220 choice-based theories, 43
Antecedent events, 68 CNS, 40
Antecedents, 114 cocaine, 46, 47
Anti-smoking laws, 258 conditioned reinforcers, 42
Anxiety, 173 CRF, 42
Assertive verbalizations, 253 depressant/stimulant effect, 41
Attention Deficit Hyperactivity Disorder drug-related behaviors, 43
(ADHD), 84 drugs, 42
Autobiographical narratives, 222 EAB and pharmacology, 41
Autonomomic nervous system (ANS), 213 ethanol, 45
Aversive stimuli, 79 Fixed Interval schedule, 41
Aversiveness, 71 Fixed Ratio schedule, 41
laboratory animals, 42
neuroscience, 40
B neurotransmission, 40
Beck Anxiety Inventory (BAI), 264 organism, 40, 44
Beck Depression Inventory (BDI), 264 pentobarbital/d-amphetamine, 41
Behavior analysis, 65, 219, 252, 253 psychiatric drugs, 39
behavioral science, 24 reinforcement function, 43
behaviorism, 24 reinforcement schedules, 42
Index 269

reinforcers vs. drugs, 43 instrument, 64

route of administration, 40 interviews, 64
second-order schedules, 42 ISCD, 64, 70, 71
self-administration procedures, drugs, 42 knowledge and understanding, 63
tobacco, 45, 46 less-frequent-use reports, 67
Behavioral processes, 51 more–frequent-use reports, 67
Behavioral science (BS), 23, 163, 169, 188 motivational events, 66
Behavioral therapies, 119 motivational operations (WMs), 61, 62, 70
Behaviorism, 24 Multidimensional Assessment
Biological and social interaction, 134 Questionnaire, 64
Linehan’s model, 134 multidimensional evaluation, 64
Biological vulnerability, 132 negative emotions, 69
Biosocial model negative punishment scheme, 68
BPD characteristics, 131 OAs, 61
emotion, 131 OEs, 61
Bipolar disorder, 63 OMs, 62
Bizarre and irrational behavior, 113 participants' profile, 64, 65
Blood-brain barrier, 40 positive reinforcement schemes, 68
Body sensations, 66 primary health care unit, 65
Borderline personality disorder (BPD), 129 reinforcing quality, 68
Brain, 7 social approach, 66
Brain sciences SPAs (see Psychoactive substances (SPAs))
anatomophysiology, 212, 213 substance dependent, 68
cells, 211 substance of preference, 66
neural communication, 211, 212 survey, 63
neurotransmitters, 212 therapist–patient relationship aspect, 65
reward system, 213 treatment leakage, 66
Brazilian Ministry of Health, 257 variables, 71
Bupropion antidepressant, 119 Central nervous system (CNS), 3, 7, 8, 12, 13,
Burn bridges, 143 15, 40, 41, 212
Chain analysis, 137
Change talk, 195, 197, 198
C Chaotic behaviors, 131
Cannabinoid substances, 10 Chemical dependence, 122, 258
Causal relationship, 249 Choice-based theories, 43
Cellular components, 213 Cigarettes, 258, 260
Center for Psycho-social Alcohol and Drugs Classic BPD patients, 134
Attention (CAPSad) Clear mind, 140, 141, 143
antecedent events, 68 Client identification, 172
behavior change, 67 Client’s problem behaviors, 110
behavioral persistence, 68 Clinical behavior analysis interventions, legal
behavioral perspective, 62 substances
collective activities, 63 ACT, 264
contingencies, 61 alcohol (see Alcohol)
daily care service, 63 alcohol cessation, 259
data analysis, 70 anti-smoking laws, 258
data collection, 63, 69 Brazil, 259
definition, 63 Brazilian Ministry of Health, 257
drug deprivation, 69 chemical dependence, 258
environments, 69 cigarette consumption, 263
family members, 66 CO measures, 263
family relationship, 66 diseases, 257
harm-reduction policy, 70 functional analysis, smoking, 263
indiscriminate function, 67 low response costs, 264
270 Index

Clinical behavior analysis interventions, legal Cognitive behavioral treatments, 83

substances (cont.) Cognitive disorder, 224
multiple pairing and functions, 262, 263 Cognitive functions, 15
National Tobacco Control Program, 258 Cognitive fusion, 150, 152
negative reinforcers, 259 Commercialization, 244
physical discomfort, 259 Committed actions, 152
psychoactive drug consumption Committee on Ethics in Research with Human
behaviors, 264 Beings (CEP/UFES), 63
psychoactive substances, 259 Communication, 133
psychoeducation, 264 Community reinforcement, 141
psychological dependence, 258 Compassion, 196
response effort, consumption, 261, 262 Compensatory response model, 93
self-management strategies, 263 Conceptual self, 151
smoking, 257, 259 Conditioned compensatory responses
social acceptance, 259, 260, 264 anticipatory stimuli, 96
social reinforcers, 259 drug administration, 94
tobacco (see Tobacco) drug cues, 96
Clinical case, TCR DRUG UCR, 95
behavioral characterization environmental stimuli, 95
client’s difficulties, 175 homeostasis, 95
control of contingencies, 176 overdose, 96
countercontrol behavior, 175 positive/negative reinforcing effects, 96
self-confidence, 175, 176 relapse
self-esteem, 175, 176 respondent processes, 96
client identification, 172 substance effect, 94
complaint, 173, 174 SUD, 96
crap night, 186 tolerance, 93, 94, 96
CRs, 188 withdrawal and craving CRs, 96, 97
desired behavior, 177 withdrawal symptom, 92, 95
HCR (see History of Contingencies of Conditioned responses (CR), 113
Reinforcement (HCR)) Conditioned stimuli (CS), 115, 220
impulsive behaviors, 187 Conditioned tolerance effect, 92
inassertive behaviors, 188 Conditioned withdrawal model, 92
procedures, 184–186 Conflict intensification, 234
substance use, 187 Conflict resolution, 254
Clinically relevant behaviors (CRBs) Consequent context, 220
client’s problem behaviors, 110 Consumption patterns, 6
CRB1, 110 Contextual self, 151
CRB2, 110 Contingencies, 61
CRB3, 110 Contingencies of reinforcements (CRs)
operant generalization, 116 anxiety, 185
out-of-session problem behaviors, 110 behavior analysis, 184
Rule 1, 110 behavioral deficits, 166
Rule 2, 111 HCR, 167, 171, 178, 181 (see also History
Rule 3, 111 of Contingencies of
Rule 4, 111 Reinforcement (HCR))
Rule 5, 112 immediate reinforcements, 178
therapist’s behaviors, 110 self-administration, PAS, 171
CNS stimulant drugs, 13 self-confidence, 179
Coca leaves, 46 substance consumption, 186
Cocaine, 13, 14, 46, 47, 84, 96, 170 tangible reinforcements, 177
Cocaine Dependence, 227 TCR, 163
Cocaine use, 6, 122 variables, 164
Codependency, 234 Contingency management (CM), 156
Index 271

ADHD, 84 experimental models, 90

antecedent stimuli, 80 exteroceptive stimuli, 98
Brazil extinction, 101
crack use disorder, 83, 84 functional analysis, substance use, 103
SUD treatments, 86 imaginal stimulation, 99
cocaine, 81, 84, 85 in vivo stimulation, 99
cocaine use disorder, 82 interoceptive stimuli, 98
drug addictions, 81 intervention method, 98
natural reinforcers, 81 memory reconsolidation, 102
positive reinforcement, 81 methodological issues, 100
punishment, 81 motivating operations, 91
reinforcement scheme, 85 negative reinforcement, 91
reinforcers, 80–82 non-reinforced reexposures, 100
SUD treatments, 82, 83, 86 operant and verbal responses, 100
vouchers, 81 operant conditioning history, 91
Continuous change, 130 photographic stimuli, 98
Continuous reinforcement schedule (CRF), 42 positive reinforcement, 91
Coping skills training, 103, 104 priming dose effect, 98
Countercontrol, 175, 198, 200–202 renewal effect, 101
COVID-19 pandemic, 6 respondent and operant levels, 99
Crack use disorder, 83, 84 respondent–operant interaction, 105
CRB1, 116 social learning theory, 103
CRB2, 116 stimulus exposure, 103
CRBs in-session, 123 substance use, 90, 98, 100
Creative helplessness, 149 SUD treatments, 103
Cue exposure therapy (CET) unconditioned responses, 92
alcohol CSs, 102 verbal operant level, 99
auditory stimuli, 99 video stimuli, 98, 99
aversive symptoms, 93 Cue reactivity, 90, 98
behavior analysis, 105 Cultural practices, 248, 249, 253
behavioral processes, 93
clinical implications, 97, 104
clinical setting, 103 D
cocaine Daily care service, 63
conditioned stimulus, 90 Data collection, 63, 69
unconditioned stimulus, 90 DBT for substance abuse disorder (DBT-SUD)
conditioned compensatory response, 92 commitment strategies, 135
conditioned response common practices, 136
alcohol use disorder, 102 community reinforcement importance, 135
cocaine, 91 empirical support, 144
extinction, 102 life-threatening uses, 136
respondent–operant interaction, 102 pretreatment, 135
substance use, 91, 92, 102 procedures, 129
conditioned tolerance effect, 92 stage 1, 136
conditioned withdrawal model, 92 subcategories, 136
conditioning theory, 90 therapist’s challenges, 135
coping skills training, 103, 104 DBT intervention strategies
craving levels, 99 acceptance, 137
dependence level, 98 change paradigm, 137
drug CSs commitment strategies, 138
reinforcement, 93 dialectical paradigm, 139
self-administration responses, 93 implemention procedures, 138
drug-related CSs, 91 patient’s experience, 138
drug-seeking responses, 101 simplicity/mechanism, 138
272 Index

DBT intervention strategies (cont.) verbal correspondence, 31

solution analysis, 138 verbal responses, 31
therapeutic objective, 138 Dialectical abstinence, 139, 140, 143
therapist–patient dyad, 138 Dialectical behavioral therapy (DBT)
validation, 137 addiction-oriented procedures, 129
DBT ranking behaviors, 135 behavior analysis, 129
DBT-SUD specific strategies biosocial model, 131–132
adaptive denial, 142 BPD, 129
alternative rebellion, 142 DBT-SUD (see DBT for substance abuse
building new bridges, 141 disorder (DBT-SUD))
burning bridges, 141 effective therapeutic processes, 130
community reinforcement, 141 fundamental treatment-orienting principles,
dialectical abstinence, 139–141 130, 131
patient consultancy vs. environmental gold-standard treatment, 129
intervention, 142 intervention process, 134
substance use disorder, 139 intervention strategies (see DBT
DBT-SUD stages, 136 intervention strategies)
Defusion, 149, 150, 152 standard behavioral therapy, 130
Degree of aversiveness, 250 substance use, 129, 135
Dementia, 224 Differential reinforcement of low rates
Dendrites, 211 (DRL), 46
Denunciation, 250, 251 Disagreement, 234
Dependency, 22 Disclosure processes, 154
Depressive disorder, 147 Disulfiram, 45
Depressive pattern, 113 Domestic/intrafamily violence, 252
Destined for learning, 65 Dopamine, 47
Diagnostic and Statistical Manual of Mental Drug abuse, 78, 185, 249
Disorders (DSM), 29, 30, 168 Drug addiction, 21, 209, 252
Diagnostic criteria, SUD Drug conditional response (DRUG CR), 95
abstinence syndrome, 36, 37 Drug deprivation, 69
aversive events, 32 Drug unconditional response (DRUG
choice and schedule interventions, 34, 35 UCR), 95
consume larger quantities, 30 Drug use, 173, 181, 253
consumption behavior, 32 Drug use paraphernalia, 141
declaration, 31 Drugs use, 3
desire, 31 Dysfunctional emotional regulation, 134
didactic character, 37 Dysthymia, 117
DSM-V, 29, 30
impulsivity/self-control paradigm, 35
individual's demand behavior, 33 E
natural selection, 34 Ecstasy use behavior, 56
non-correspondence, 31 Effective DBT conduct, 136
nonverbal responses, 31 Eliciting stimulus (ES), 220
operants vs. reflexes, 33 Emotions, 98
persistence, drug use, 33 complex group interaction, 132
recovery time, 34 definition, 131
reflexes, 32 effects, 132
reinforcement sources, 34 subsystems, 131
relapse, 32 transcultural, 131
self-administration, drugs, 33 Emotion dysregulation, 133
social/health problems, 36 Emotional dysregulation, 132, 133, 144
subjective value, 35 Emotional regulation, 132, 134
tolerance, 36 Emotional responses, 134
verbal behavior, 30 Emotional stimuli, 133
Index 273

Empathy, 14 Rule 4, 119

Endocannabinoids, 10 Rule 5, 119
Enteric nervous system (ENS), 213 self-monitoring, 118
Entering the paradox, 139 self-reported measures, 120
Epidemiological data, 4–6 social interactions, 117
Erythroxylon coca, 13 strategies, 120
Erythroxylum coca, 46 therapeutic context, 119
Escape/avoidance behavior, 249 treatment plan, 117
Escape/avoidance responses, 247 voluntary admission clinic, 121
Establish/abolish drug use behavior, 61 FAP conceptual framework, 124
Establishing operations, 69 FAP psychotherapeutic model, 112, 120
Ethanol, 45, 215 FAPRS categorization system, 112
Evocation, 195 FAPRS instrument, 121
Exhibitionism, 118 Female emancipation, 244
Exhibitionist behavior, 118 Feminist ideas, 244
Exhibitionist tendencies, 118 Feminist movements, 244
Experimental Analysis of Behavior Financial dependence, 250
(EAB), 39, 41 Five Therapeutic Rules, 110
Exposure and response prevention (ERP), 90 French Revolution (1789), 244
Extension project, 251 Functional analysis, 62–64
Exteroceptive stimuli, 98 Functional analysis, clinical case formulation
adulthood, 57
alcohol, 57, 58
F alcohol-consuming behavior, 55
Family and social organization, 244 behavioral therapy, 53
FAP application, clinical conditions, 112 children, 57
FAP applications, substance dependence distal variables, 55
case conceptualization, 121 drug use and dependence, 59
CBT, 117 drugs, 55
complex clinical cases, 119 ecstasy use behavior, 56
contingencies, 118 history, 56
counter-control behavior, 121 intermittent reinforcement, 57
CRBs, 122, 123 negative educational practices, 56
diagnostic criteria, 117 parental educational practices, 56
efficacy and effectiveness, 124 parenting dimensions, 56
eliminating bulimic behavior, 117 permissive parenting, 57
functional analysis, 118 physical and emotional violence, 58
interpersonal functioning, 120 positive educational practices, 56
interpersonal interventions, 120 positive parenting practices, 57
interpersonal repertoire, 117 psychoactive substances, 53
intimacy avoidance behaviors, 121 social contingencies, 55
pharmacological effect, 118 social reinforcement, 55
positive reinforcement stimuli, 117 stimulating substances, 55
pre-established sessions and Functional analysis, substance use
interventions, 120 and dependence
process measurements, 119 behavior analysis, 51
psychotherapy, 117, 121 Functional analytic psychotherapy (FAP)
public exposure, 118 adjunct intervention, 115
reexperience and hyperexcitability, 117 CRBs (see Clinically relevant
reinforced in-session, 119 behaviors (CRBs))
romantic relationships, 122 CRBs relationship, 110
Rule 1, 118 interpersonal problems, 112
Rule 2, 118 psychotherapeutic process, 112
Rule 3, 118 psychotherapeutic relationship, 109
274 Index

Functional analytic psychotherapy I

(FAP) (cont.) Illegal substances, 263
psychotherapy, 109, 115 Illicit drugs, 4–6, 10, 11, 15
therapist/client behaviors Illicit substances, 6, 261
classification, 110 Impulsivity-related genes, 133
Functional Analytic Psychotherapy Rating Indiscriminate function, 67
Scale (FAPRS), 111 Individual’s repertoire, 113
Functional behavior analysis, 59 Industrial Revolution (1848), 244
Industrialized cigarettes, 9
Insomnia, 66
G Intact emotional skin, 133
Gamma-aminobutyric acid (GABA), 45, 212 Intellectual Disability, 224
Gap junctions, 212 International Classification of Diseases
Generalization, 112, 121, 134 (ICD), 30
Genetic influence, 132 Interoceptive stimuli, 98
Glial cells, 211 Interpersonal effectiveness skills, 144
Grug consumption, 4 Interpersonal repertoire, 109, 112, 122
Interviews, 64
Invalidating environment
H emotional responses, 133
Habituation, 247 individuals’ expressions, 133
Harmful behaviors, 246 natural emotional experiences, 133
Headache, 66 primary characteristics, 133
Health organizations, 6 Inventory of drug use situations (ISCD), 63
Health Rehabilitation Program, 223 ISCD generated data, 64
History of Contingencies of Reinforcement
(HCR), 167
affective indifference, 181 L
anxiety, 183 Legal substances, 260, 261
contingencies of reinforcement, 178 Liberalization, 244
countercontrol, 183 Licit drugs, 5, 7, 260, 261
drug use, 181 Likegram, 154–156
environment, 183 Lowered self-confidence, 250, 251, 253
free reinforcement, 177 Lowered self-esteem, 250, 251, 253
immediate reinforcements, 178 Lysergic Acid Diethylamide (LSD), 15, 16
imprudence, 180
impulsivity and low frustration tolerance,
180, 181 M
PAS, 183 Male aggression, 248
pharmacological reinforcements, 182 Marijuana
psychotherapeutic goals, 183 abstinence, 11
psychotherapy, 183 abusive use, 10
self-confidence, 179 cannabinoid receptors, 10
self-esteem, 179 chronic use, 10, 11
self-knowledge, 181 combined use, 11
sensoriality, 179, 180 drug abuse vs. psychiatric
sensoriality behavior, 180 comorbidities, 11
social reinforcements, 177, 181, 182 factors, 10
superstitious behavior, 179 illicit drugs, 10
tangible reinforcements, 177 internal stimuli, 10
Hospitalization, 122, 238 physical effects, 10
Human behavior, 59 psychobehavioral effects, 10
Human evolution, 248 psychobiological aspects, 11
Hypothetical behavioral processes, 137 psychosis, 11
Index 275

psychotic behaviors, 11 Multiple substance-dependents, 230

respiratory infections, 11
Marijuana use, 119
Mechanisms of change, 197, 198 N
Medicines, 209 Narrative interview, 224
Mental health diagnostic manuals, 113 Narratives analysis
Mental vacation, 142 behavioral functions, 222
Methamphetamines, 6 couple’s history, 223
Mindfulness, 137, 148, 150 couple’s narratives, 225–227
Mindfulness-based sobriety, 148 data analysis procedures, 224, 225
Molar contingencies, 167 international research, 223
Molecular contingency analysis, 166 interviews, 224
Monoaminoxidase (MAO), 12 marital relationship, 222, 223
Motivating operations (MOs), 91 methodological fact, 222
Motivational events, 66 participants, 223
Motivational function, 220 personal experiences, 221
Motivational interviewing (MI) relationship’s history, 221
addiction treatment, 193 self-narratives, 222
ambivalence, 195 substance-dependent individuals, 221, 222
amplified reflection, 201 verbal report analysis, 221
behavior analysis, 198 Narrative sequences
behavioral change vs. change talks, 202 behavioral functions, 228
behavioral domains, 193 final situation, 230, 237
behavioral pattern, 199 marital relationships, 227, 229–230
building motivation, 196 methodological model, 219
change talk, 194, 195, 197, 198, 200 notion, 223
characterization, 195 PAS, 231–232
communication skills, 196 phases, 219
complex reflections, 200 quinary chronological process, 219
consolidating commitment, 196 resolutions, 230
countercontrol, 198 transformations, 228, 233–234
definition, 195 National Health Surveillance Agency, 13
double reflections, 201 National Tobacco Control Program, 258
empathetic reflection, 201 Natural/biological social norms, 244
functional definition, 201, 202 Nausea, 66
informing and advising skill, 197 Negative connotation, 232
mechanisms of change, 197, 198 Negative emotions, 69
OARS communication skills, 202 Negative feelings, 150, 152
pathological liars, 194 Negative punishment scheme, 68
person-centered approach, 193 Negative reinforcers, 259
process, 196 Negative thoughts, 150
reflections, 196, 201 Nervous central system, 133
self-control strategies, 194, 199 Nervous system, 210, 211
social contingencies, 202 Neural communication, 211, 212
SUD, 193 Neurons, 41, 211, 212
sustain talk, 194, 195, 197 Neuropeptides, 212
therapeutic environment, 198 Neuroreceptors, 98
verbal behavior, 198, 200, 202, 203 Neurosciences, 26
verbalization, 201 behavioral analysis, 215
Motivational operations (WMs), 61, 62, brain and behavioral sciences, 210
66, 70, 72 nervous system, 210
Multidimensional Assessment Neuroscientific knowledge, 215
Questionnaire, 64 Neurotransmitters, 13, 15, 40, 41, 45, 46, 212,
Multidimensional evaluation, 63 214, 216
276 Index

Neutral stimulus (NS), 36 Professional performance strategies, 251

Nicotine, 45, 46, 263 Professional’s criticism, 111
Non-prescription drugs, 209 Pro-Mulher program, 253, 254
Non-violent social performance, 252 Psychiatric disorder, 77
Noradrenaline, 47 Psychiatric drugs, 39
Psychoactive substance (PAS), 99, 113, 147,
148, 153, 156
O abuse/dependence, 61
OARS communication skills, 199, 200, 202 acquisition and maintenance, 62
Obsessive-Compulsive Drinking Scale addiction process, 220
(OCDS), 264 adverse effect, 213
Occurring response (R), 220 alcohol, 7, 8, 215
Operant conditioning, 78, 79, 102 amphetamines, 12, 13
Opioids, 215 anticipatory responses, 216
behavioral analysis, 210
behavioral changes, 214, 215
P behavioral science, 169
Pan American Health Organization (PAHO), 9 characteristics, 170
Partnership, 195 chemical exchanges, synapses, 214
PAS dependence, 220–222, 225 chemical reactions, 215
Patient consultancy vs. environmental classification, 4
intervention, 142 clinical behavior analysis, 258
Pavlovian conditioning, 90, 96, 104 CNS, 3, 214, 215
Pavlovian paradigm, 216 cocaine, 13, 14
Peripheral nervous system (ANS), 212 conflict, 223
Permissive parenting, 57 cost of response, 209, 210
Person’s life history, 248 denial, 238
Personality disorder, 222–224 description, 62
Person-centered approach skills, 194 disagreement, 68
Pervasive emotional dysregulation, 132 disruption, 231–232
Pharmacology, 39, 213 drug addiction, 209
Physical dependence, 258 drug vs. receptor, 213
Physical discomfort, 259 ecstasy, 14, 15
Polarity principle, 130 emergence and maintenance, 72
Positive and negative consequences of the ethanol, 215
behavior, 137 feeling better, 69
Positive reinforcement schemes, 68 final situation, 230
Positively reinforcing aspects, 250 HCR, 171
Post-hospitalization session, 143 inhalants, 12, 13
Postsynaptic, 41 intensity/frequency, 70
Posttraumatic stress disorder (PTSD), 117 intermittent reinforcement, 67
Post-war scenario, 245 LSD, 15, 16
Pre-synaptic, 41 maintaining use, 220
Prevention marijuana, 10–12
(re)occurrence, 61 marital relationship, 229–230
crime, 63 mortality rate, 216
public and private drug, 62 motivational variables, 69
relapse, 64, 71 negative consequences, 4
Priming dose effect, 98 neurotransmitters, 214
Private behaviors, 208 occurrences/recurrences, 62
Private events, 114 opioid analgesics, 215
Private service, 119 P3, 67
Procedural self, 151 pattern of use, 222
Professional intervention, 62 Pavlovian paradigm, 216
Index 277

pharmacology, 213 Rat Park, 23

physical and social environment, 171 Recognition of aggression, 252
physiological aspects, 210 Reductionism, 214
physiological changes, 259 Reflections, 196
positive/negative reinforcers, 53 Reflex, 23, 32
prevalence, 63 Rehabilitation, 171
progression, 225, 236 Reinforcement schemes, 113
psychostimulants, 214 Reinforcers, 249
reduced frequency, 67 Reinforcing consequences, 144
reductionism, 214 Relapse
resolutions, 230, 235–236 prevention, 64, 71
social acceptance, 262 Relational Frame Theory (RFT), 149, 202
solvents, 12, 13 Renewal effect, 101
substance dependence, 168, 219, 220 Renewal of response, 101
survey, 209 Repertory restriction, 115
TCR, 164 Resolution, 236
tobacco, 9, 10 Respondent–operant interaction, 102, 105
transformation, 233–234 Response class, 110
unconditioned boosters, 69 Reward system, 213
unconditioned stimuli, 169 Romantic relationships
Psychoeducation, 264 aggressors, 247
Psychological assistance, 251 cultural practices, 248, 253
Psychological dependence, 258 drug use, 253
Psychological flexibility, 149 love concept, 247
Psychology, 25, 26 non-denunciation, 247
Psychopathologies, 77, 113, 115 victim’s affection, 247
Psychosis, 11 violence, 247, 253
Psychostimulants, 214, 215
Psychotherapeutic intervention, 115
Psychotherapeutic model, TCR S
analysis, molar contingencies, 167 Satisfactory therapeutic development, 137
behavioral deficits, 166 Schizophrenia, 63, 224
CRs, 164–167 Science, 25
functional difficulties identification, 165 Self-administration, substances
HCR, 167 animals, 78
interpersonal relationships, 166 aversive stimuli, 79
molecular contingency analysis, 166 behavioral pharmacology, 78
problem behavior, 167 conditioned negative reinforcers, 80
professional’s investigation, 166 conditioned positive reinforcers, 79, 80
psychotherapeutic procedures, 168 data, 79
psychotherapeutic process, 165, 168 operant conditioning, 78, 79
psychotherapist’s interventions, 167 reinforcing effects, 80
science, 167 unconditioned negative reinforcers, 80
Psychotherapeutic procedures, 168 unconditioned positive reinforcers, 79, 80
Psychotherapy, 163, 173 Self-confidence, 176, 179
PTSD symptoms, 117 Self-control, 57
Public behaviors, 208 Self-destructive cycle, 143
Public policies, 251 Self-esteem, 176, 179
Self-harm, 134, 143
Self-knowledge, 121, 181
R Self-management, 57
Radical acceptance, 137 Self-valorization verbalizations, 185
Radical behaviorism, 23, 24, 29, 30, 151, 163, Semi-structured interview, 63, 64
188, 208 Sensoriality, 179, 180
278 Index

Sensoriality behavior, 180 social reinforcers, 170

Serotonin, 15, 47 SPAs, 169
Service protocol, 252 therapy questions, 170, 171
Sexual pattern, 118 withdrawal syndrome, 114
Smoking, 257, 259, 261 Substance use and dependence
Social acceptance, 259, 260, 262 behaviors, 21
Social consequences, 253 functional analysis (see Functional
Social contingenciesfv, 249 analysis, clinical case formulation)
Social dynamics, 249 patterns, 23
Social learning theory, 103 pharmacological characteristics, 23
Social psychology, 193 public health, 21
Social reinforcement, 55, 181, 182, 262 Rat Park, 23
Social reinforcers, 170, 259 social context, 22
Solvents/inhalants, 12, 13 theoretical models, 22
Somatic nervous system (ANS), 212, 213 Substance use disorder (SUD)
Spirit of motivational interviewing anxiety disorders, 147
acceptance, 195 behavioral repertoire, 77
compassion, 196 Brazilian population, 89
evocation, 195 clinical models, 89
OARS communication skills, 199 licit substance use, 5
partnership, 195 psychiatric disorder, 77
Spouses, 223 self-administration, 78
Standard DBT, 135 theoretical models, 89
Stereotyped condition, 113 treatments, 147
Straw cigarettes, 9 Suffragist movements, 244
Substance abuse, 117 Superstitious behavior, 179
Substance dependence, 62 Sustain talk, 195, 197
abstinence syndrome, 114 Synapses, 41, 214
analysis (see Narative analysis) Systemic Couples Therapy (SCT), 223
antecedents, 115
behavioral functions, 238
consequences, 115 T
consumption progression, 232 Therapeutic interventions, drug-dependent
CRs, 171 individuals, 221
CS, 113 Therapeutic process, 139
diagnostic criteria, 168, 169 Therapist–patient relationship aspect, 65
drunkenness, 114 Therapy by Contingencies of
DSM, 168 Reinforcement (TCR)
escape-avoidance behaviors, 114 Behavioral Science (BS), 163, 188
family’s effective participation, 238 contingencies of reinforcement, 163
FAP psychotherapeutic model, 116 diagnostic manuals, 164
HRC, 171 mental health professionals, 164
individual and drug relationship, 113 PAS, 164
interpersonal repertoire, 115 psychotherapeutic model (see
interventions, 220 Psychotherapeutic model, TCR)
knowledge, 236 psychotherapy, 163
neutral stimuli, 169 substance abuse, 163
operant contingency, 114 substance dependence, 163
PAS, 168–170 Three-term contingency, 52
phenomena and effects, 238 Tobacco
problem management, 236 behavioral dependence symptoms, 9
psychotherapeutic advances, 172 Brazil, 258, 259, 261
sensitivity, 115 cancer types, 10
serious consequences, 114 cigarettes, 260
Index 279

cigarette smoke effects, 10 V

consumable forms, 9 Validation, 137
diseases, 10 Verbal behavior, 198, 200, 202, 203
functional analysis, smoking, 263 Verbal community, 186
health, 258, 260 Verbal descriptions, 260
inhalation, 9 Verbalizations, 173, 174, 253, 254
laws and measures, 258 Victim’s’ self-silencing, 250
legal substance, 261 Violence, 243, 253
National Tobacco Control Program, 258 Violence against women
nicotine, 45, 46 civil acts, 245
occasional use, 9 counterculture movement, 246
physical symptoms, 9 cultural bias, 245
products, 257 cultural practices, 253
psychoactive substances, 258 custom of killing, 245
psychological dependence symptom, 9 drug use, 249
social acceptance, 260, 264 features, 246
types of symptoms, 9 feminist movements, 244, 246
verbal descriptions, 260 formulated rules, 244
withdrawal, 258 frequency and severity, 243
Tolerance, 36, 93, 94, 96, 114 public policies, 251
Trained DBT skills, 136 punishment, 245
Transformation, 232, 234 reports, 246
Triggering event, 137 romantic relationships, 246, 253
Triple contingency analysis, 220 sexual relationship, 243
unemployment, 248
women’s murder, 245
U Violence and drugs frequency, 249
Unconditioned responses (UR), 113 Violent behavior, 249
Unconditioned stimulus (US), 113, 220 Virtual reality, 100
Unemployment, 174 Virtual stimuli, 99
United Nations Office on Drugs and Crime Visceral nervous system (ANS), 212, 213
(UNODC), 5, 6 Vulnerability factors, 137
Use of substances
consumption patterns, 6
education and awareness, 17 W
epidemiological data, 4–6 Watsonian behaviorism, 24
perception, 21 Wholeness and interrelatedness principle, 130
political-criminal context, 16 Withdrawal symptoms, 92, 95, 116
positive/negative reinforcing effect, 3 (see Withdrawal syndrome, 114, 115
also Psychoactive substances) Woman’s permanence perspective, 250
risk factors, 7, 16 Woman’s sexual relationship, 245
risks, 4, 16 Women’s right institution, 245
Women’s rights movements, 244
Women’s role in society, 243
Women’s socialization, 246