1) When is the best time to administer a reward or punishment?
2) How much of a reward or punishment is needed?
3) How often should we deliver a reward or punishment?
4) What type of reward or punishment works best, and under which conditions?
A substance or activity can only become addictive if it is rewarding; i.e., if it is pleasurable or enjoyable (at least initially). Individuals who dislike particular substances or activities have little risk for developing an addiction to those substances or activities. Such dislikes are not uncommon. Some people do not enjoy certain substances or activities. This protects them from developing an addiction simply because those substances or activities are not enjoyable. They are not rewarding.
Addiction is a learned behavior because the initial pleasure or enjoyment was rewarding. According to the principles of operant conditioning, rewarded behaviors will increase. Of particular concern is that most addictive substances and activities are immediately rewarding. Research has taught us that when we immediately reward a behavior people (and animals) learn it more quickly. This also explains why the addictive substance or activity tends to replace other, more healthy sources of reward. These other types of rewards are frequently delayed (such as the return of good health). An unfortunate cycle also develops. As addiction progresses, the availability of natural, healthy pleasures (rewards) decline due to the addiction. Friendships are strained. Loved ones become bitter. Meaningful jobs or hobbies are lost or abandoned. When this happens, addicted people become more and more dependent on their addiction as their sole source of reward. This creates an unfortunate but powerful addictive cycle.
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Punishment also plays an important role in the development of addiction. If there is an early and significant punishment (perhaps a DUI, or a medical problem) then the addiction might not develop. In many cases, punishments for addiction occur much later, when the addiction is already firmly in place. At this point, many chemical and physiological changes have already occurred in the brain. This makes it more difficult to discontinue the addiction. Simultaneously, unhealthy cognitive and emotional patterns have become well-established. This too makes it more difficult to change addictive behavior. Therefore, in these later stages of addiction punishment alone is usually insufficient to create a lasting change. The most successful approach is to increase rewards for healthy behavioral choices while eliminating rewards for addictive behavior.
Operant conditioning has resulted in several effective treatments. The basic idea is to reward addicted people for making healthier, recovery-oriented choices. However, research has made it very clear: The rewards must have some value, and the reward must be substantial. Again, this has a common sense ring to it. It's unlikely an addicted person would give up their addiction for a piece of chocolate. However, they might give it up for a car!
It follows that what might be rewarding to one person, would be meaningless to the next. For a very hungry person food might be very rewarding. However, if someone just finished a Thanksgiving feast, food is unlikely to be rewarding. Addictions research has demonstrated that by rewarding some people with inexpensive but desired items they can increase the number of abstinent days. This is particularly true for people with limited financial means. These same inexpensive items would not likely serve to change the behavior of someone with greater financial means.
CRAFT is a therapy that relies on operant conditioning (Community Reinforcement and Family Training; Meyers & Wolfe, 2004). The social portionof the Bio-Psycho-Social-Spiritual model stresses the importance of interpersonal relationships. Therefore, addiction treatment often needs to include family members or other people who have a close personal relationship with the addict.
CRAFT teaches concerned significant others (CSO's) to reward the addicted person's positive, healthy behaviors. These behaviors oppose addiction. The CSO's also learn to remove rewards for unhealthy behaviors. These behaviors support addiction. For instance, a wife may plan a pleasant evening for her husband when he comes home from work, without stopping at a bar. However, if he comes home drunk, her kind attention is withdrawn. In this case, she would excuse herself from his company for the rest of the evening. By rewarding healthy behavior, and withdrawing rewards for unhealthy behavior, the wife is applying the principles of operant conditioning. This approach will increase the husband's healthy behaviors but only if quality time with his wife is rewarding. Another husband might find time alone to be more rewarding. Once again, we must target the rewards to each person.
CRAFT teaches family members to allow the negative consequences of addiction to affect the addicted person directly. This is often difficult for family members. Out of care and concern for their loved one, they have prevented these consequences from occurring. Moreover, these negative consequences often affect the entire family, not just the addict. For example, suppose a spouse loses his/her job because of irregular work attendance due to addiction. This loss of income has a huge impact on the entire family! Therefore, it is quite natural for the healthy spouse to try to prevent these sorts of problems.
Regardless of the loving motives of family members, removing the negative consequences serves to prolong addiction. In contrast, allowing these consequences to occur serves as a deterrent (punishment). For instance, if a wife misses work on Monday morning because she has a hangover, her husband does not call in to work for her. Instead, he lets her make the call herself. In some severe situations, CSO's may even apply negative consequences of their own (such as moving out of the house). However, these sorts of drastic negative consequences (punishments) are the last resort, not the first. Research has made it clear: People maintain positive behavior much longer when they expect a reward, rather than a punishment.
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