Editor’s note: This is the fourth in a series of five articles that concentrate on what’s working in the trenches for frontline counselors.

Motivated clients, even when committed to treatment, require recovery tools designed to translate motivation into tangible learning strategies and new behavioral habits for managing their addictive disorders. Regardless of where a client rests on the treatment continuum, the counselor who uses a cognitive-behavioral model explores learning strategies that guide the client’s development and ignite a dynamic reeducation process.

This article introduces six cognitive-behavioral recovery tools — classical conditioning, contingency management, cue exposure treatment, contracts for recovery, coping skills, and charting daily habits — that achieve those ends. These recovery tools bring structured expectations to the treatment process. They focus on dealing with thoughts and behaviors in the present, rather than on uncovering underlying issues from the past.

Each of these recovery tools, while employing a distinct methodological approach, provides insight into the development of new behavioral habits that place clients in greater control of their lives and environment. Addictions appear as habits that, in some cases, provide clients with an illusion of control. The common goal of each of these tools is to help clients replace addictive habits with new, healthy habits that support recovery by creating instruments of control.

Classical conditioning
Because many addiction clients believe that their environment controls them, it can help to teach them how the relationships defined in classical conditioning apply to their specific addiction. Understanding this connection can help them modify their addictive behavior by implementing strategies such as Aversion therapy and Counter conditioning (Davidson & Neale, 1994) to bring an addictive behavior to extinction and create a more positive habit using the same principles. Ivan Pavlov defined classical conditioning as a process involving a neutral stimulus (i.e., a bell) paired with an unconditioned stimulus that triggers an automatic response, which requires no learning (e.g., food). In this famous experiment, Sam the dog became conditioned to respond to the neutral stimulus (bell), without the unconditioned stimulus (food) (Pavlov, 1960). It is helpful for addiction counselors to be aware of the parallels of Pavlov’s construction and addictive behaviors. This awareness can guide the client toward extinguishing and replacing an addictive behavior.

Pavlov’s research revealed the following insights that define simultaneously the terms of the behavior to be modified and the manner in which a new habit can be structured:

a) Reinforcement creates a conditioned response (CR) that gradually disappears without reinforcement.

b) Extinction occurs when the conditioned stimulus (CS) returns to a neutral stimulus (NS), i.e., occurs when the bell is rung and no food follows.

c) Generalization occurs when a conditioned response is elicited by another similar neutral stimulus [the sight of an object that looks like a bell gets a similar response as the conditioned stimulus bell].

d) Spontaneous Recovery occurs after there has been extinction and the neutral stimulus relapses to the original conditioned stimulus.

Four steps to extinction
Awareness is the desired outcome of this application. An example of applying Pavlov’s theory to a clinical setting involves:

1. Explain and teach the tenants of classical conditioning using examples relevant to the client’s current state of addiction.

2. Make a list of all the potential environmental triggers that may have become classically conditioned (e.g., a favorite perfume). Have the client explore his or her present addictive disorder(s) by exploring the relationship between CS and CR. The client explores in detail all perceived pairings (NS + UCS = CS) and sorts them out in writing to visually see the linkages.

3. With the counselor’s help, the client identifies different behaviors, thinking and emotional consideration(s) for extinction. Then the client is asked to monitor daily behaviors for 90 days through the use of an extinction log, which the client brings to counseling for guidance and reinforcement.

4. In the 90-day critical debriefing, the counselor and client evaluate the extinction log and measure progress. The counselor and client revisit Step 1 and make a decision if Step 2 is to be repeated for another 90 days.

For more information on classical conditioning, see Corsini and Wedding (2000), Corey (2001), and Better Mental Health through the Pavlovian Paradigm — Innovations (n.d).

Contingency management
Early in life, most of us learn that our actions always have consequences. Addicted clients, blinded by the euphoria of addictions, are unable to see the negative consequences of their behavior. Contingency management, influenced by the work of B.F. Skinner (1971), is a cognitive tool that focuses on changing maladaptive behaviors by controlling consequences. Known as behavior modification, this process makes use of positive reinforcement (rewards for appropriate behavior), and punishment (negative consequences for maladaptive behavior). Regarding punishment, the objective is to develop predetermined consequences for addictive behavior.

For example, if the desired behavior(s) are not achieved, the desired reward is withheld (e.g., no Friday night movie). It is important to understand that punishment is not to be damaging to the client but rather serves as a motivator that stresses accountability in the treatment process. Contingency management promotes the application of positive rewards for short-term goal success. Research points out that rewards can become primary drivers for motivating learning (Friedman & Schustack, 2003). Budney, Sigmon, and Higgins (2001) explain that “controlled clinical studies have shown that contingency management interventions can enhance therapeutic outcomes across a wide range of substance abuse treatment populations” (p. 149).

The counselor who uses contingency management as a treatment tool must, as a result, work with clients to determine positive rewards. For example, a client who is trying to cut down weekend alcohol consumption, using a harm-reduction orientation, makes the contract: if he goes for two weeks without a drink, he will allow himself to enjoy two drinks maximum when he goes for supper at a pub. If he does not comply, he withholds the reward of going out, this being the predetermined consequence. When implementing this treatment strategy, it is important for the counselor to be aware of the steps that define the contingency management.

Steps for developing contingency management plans
1. Define the desired target outcome and the criteria used to measure success (e.g., urine test weekly). These determinants will come out of the treatment-planning process.

2. Make sure the contract clearly defines the expectations and agreements and is congruent with the treatment program. Both positive rewards and consequences can be chosen to reinforce behavior.

3. Specify the following items in detail: dates, times, frequency, duration, measurements, monitoring of specific processes, risk management issues, relapse prevention, positive reinforcements, and punishments.

4. Put the contract in writing with the above criteria and have the client sign and date it.

For additional information on contingency management plans, see Higgins, Wong, Badger, Ogden, and Dantona (2000) as well as Kirby, Amass, and McLellan (1999).

Cue exposure treatment
Cue exposure is therapy designed to reduce relapse in addictive behavior by tempting clients with stimuli that induce cravings to drink/consume while preventing the client from actually participat-ing/satisfying the craving. Cue exposure is a relatively new recovery tool that considers tolerance, withdrawal, and cravings for drugs/alcohol as conditioned states that are amenable to change or extinction (Eliany & Rush, 1992). This exposure allows the client to create habits of resistance and refutation of the temptation.

Cues are specific to the addiction. For example, an alcoholic may find a cue in the sight or smell of a favorite beverage, in the mood states or situations in which drinking previously occurred, or in the people, places, times, and objects that had previously been associated with alcohol’s pleasurable effects. While cue exposure is seen as a realistic treatment tool that increases self-efficacy and reduces desire, it is not without risk. The very stimuli that trigger a client’s addictive behavior are used to create the habits of resistance. Cue exposure approaches require the addiction counselor to be trained and supervised both to mitigate risk and manage the intensity of the session. Thus this article does not provide an application outline for cue exposure; the goal is only to introduce you to this concept for your consideration.

The rationale for this treatment approach stems from clinical studies, which have found that many patients retain cue reactivity (cravings) after treatment (Chiauzzi & Liljegren, 1993). For example, Childress, McLellan, Ehrman, and O’Brien (1988) found that opiate-addicted individuals who achieved abstinence in treatment still presented physiological arousal to drug cues 30 days after treatment completion. Similar results have been found with cocaine (Washton, 1989) and alcohol users (Cooney et al., 1987). Given that cues augment relapse potential (Niaura et al., 1988), it has been argued that treatment can become an exercise in futility when the addicted person is re-exposed to relapse cues in his or her natural environment over a period of time.

For more information on cue exposure treatment, see Bouton (2000) and Drummond, Glautier, and Remington (1995).

Contract for recovery
Even motivated clients need a highly structured treatment environment and will benefit from using contracts in the recovery process (Talbott & Crosby, 2001). A recovery contract is an action plan that defines the milestones (e.g., an AA 30-day clean chip or predetermined physician examinations) that must be achieved to result in positive treatment outcomes. The addiction counselor works with the client to develop a specific step-by-step recovery contract based on the mutually agreed upon treatment plan. Updated on a regular basis throughout treatment to integrate factors (e.g., risk management and relapse prevention) that are prone to change, recovery contracts should be considered a unifying treatment document by including details such as: exact time and dates for actions, support systems, progression of goals, and measurement of progress.

A recovery contract takes time, effort, and focus to create and implement because its goal is to outline the behaviors essential for a successful recovery. A well-conceived recovery contract will help fuel a client’s motivation as well serve as a practical guide for day-to-day living. This structure helps the client deal with daily life stress and decision-making, and avoid distractions. This tool can be effectively used in intensive outpatient, primary inpatient, and continuing care settings. Recovery contracts are most effective when the client’s support systems (e.g., family) are involved in the process and are aware of the contract specifics.

Four steps for creating a contract for recovery
1. The client and the counselor develop a recovery contract (not legally binding) based on the client’s treatment plan. Its purpose is to remove distractions and keep the client focused on a plan with well-thought out action steps. Establish expectations by taking a seven-day calendar and defining the action steps the client will be taking in the morning through the evening every day until “completion.” Clearly outline the consequence for breach of contact.

2. Establish a recovery contract support team. The client will need to sign a release of information document before the counselor can work with the support team directly. However, involving caring family members and peers supports the treatment efficacy of the contract.

3. Develop an emergency action plan outlining clear action steps in the case of a relapse. These steps must be included.

4. Present the final recovery contract to the client, who signs and dates it. The most effective contracts tend to be no more than one page, so as not to overwhelm the client. It is important to review the contract in detail to ensure client comprehension. The recovery contract team receives a copy of the contract so that accountability can be determined. Finally, set the reporting plan.

For more information about recovery contracts, see Talbott and Crosby (2001) and Talbott (1995).

Coping skills training
Coping skills (also called affect-regulation) is a strategy for helping clients to effectively manage stress, anxiety, anger, or frustration without resorting to their addictive disorder (Lazarus & Launier, 1978). “Affect-regulation training seeks to help addicts develop an internal rather than external locus of self-control, facilitating acceptance of personal responsibility for change so they can reap the emotional benefits of their efforts” (Scott, Kern, & Coombs, 2001, p. 192). Addicts tend to be “compulsive and ritualistic, relying on alcohol and other psychoactive drugs to help maintain their mood, energy and or arousal levels” (p. 192). The realization that external forces do not control them can help clients displace motivations and feelings that come from active addictive disorders. Coping skills can assist clients to tune into internal motivations.

Coping skills are specific to the experiences, fears, and commitment of the particular client. Coping skills techniques must be supportive of the client’s treatment needs. The client’s mastery of coping skills does not happen overnight. There is a transition phase in which the client will need support to cope with the uncomfortable emotions and feelings. Coping skills are instrumental in affording the client the respite from uncomfortable circumstances that can be potentially devastating to recovery. When integrating coping skills into the treatment environment, consider the following four-step model.

Four-step coping skills model
1. Set the environment. The client needs to feel that the counseling environment is a safe place to learn coping skills. The counselor’s first role is to build rapport and trust.

2. Evaluate the client’s core coping skills informally. The core coping skills that the counselor will explore through general open questions are related to emotions and/or environments that are associated with the client’s addictive behavior.

3. Create an action plan with the client to learn core coping skills using a variety of strategies: support groups, bibliotherapy (e.g., assigning Daniel Goleman’s Emotional Intelligence or David Burn’s Feeling Good Handbook) or specific psychosocial workshops (self-esteem). Once the coping skill design is developed, it needs to be put into a formal format so that the client is clear of the actions and desired outcomes.

4. Follow up by reviewing with the client on regular basis his or her progress in general and his or her progress in the area of coping-skill development.
For additional coping skills resources, see Goleman (1995), Monti (1989), and Scott, Kern and Coombs (2001).

Charting daily habits
Progress in counseling can be difficult to qualify. Engaging a client in the proactively charting daily habits creates a cognitive process that monitors and regulates daily behavior (Bandura, 1978). In essence, identifying desired new habits and developing a charting program to implement those habits provides the client with a tangible tool to reinforce and measure progress.

The habit chart is a tool that promotes self-awareness by making concrete the expectations, thoughts, goals, and plans that will directly impact the client’s behavior and learning. As Bandura (1997) explains, reinforcing a behavior that was positive in the past will assist the client to repeat the habit in the present.

This tool is influenced by Benjamin Franklin, who developed habit charting before psychology or addiction counseling was established (Friedman & Schustack, 2003). Franklin’s chart listed 13 core competencies that he wanted to focus on each day, including moderation, resolution, and order. This pragmatic self-help approach provides insight into the residual value of the quest for perfection: Franklin did not believe it was possible to attain such lofty goals; however, he owned the insight that daily focus helped him to be a better and happier person. His approach reduced the behaviors and actions of success into smaller manageable activities. By simplifying the tenants of success, he invented a tool to create positive habits that still carries considerable value today.

Four steps for developing habit charts
1. The client first determines what habits he or she wants to reinforce daily, up to a maximum of five. With progress the client can add to the list; yet the counselor must not overwhelm the client in the early stages with excessive habits.

2. The client clearly defines what each habit is and the activities associated with that behavior (e.g., honesty and non-judgmental activities). This often takes time, but is an excellent process for teaching normalizing social standards.

3. The counselor and client build a weekly habit chart template, ensuring there are several copies and a master. The goal is to use the habit chart for 30 days before a critical assessment.

4. The client starts a daily habit chart, each day checking a box (3) that represents the successful completion of the daily habit. Failure to complete the habit results in an X, which is a reminder that the client has the opportunity the next day to focus on the assigned habit. If the client continues to see X’s, it may be an indication that the client lacks a core competency and needs further reevaluation of needs and wants. Many times, clients are not aware of microskills needed to achieve daily success. This process helps them start to focus on the mechanisms involved in developing new habits.

For additional habit-charting resources, see Covey (1990).

Creating new habits
Implementation of the 6 C’s is predicated on patience, a shared level of self-awareness by both the client and counselor, and a realization that the rewards of treatment are the result of a long and sometimes arduous journey. When clients confront the challenges of learning new habits, they are able to manage expectations and recognize that stressful conditions could easily prompt relapse.

An old adage says we must learn to walk before we run. This conception of learning applies to clients who seek the freedom earned in the creation of new habits. Creating new habits helps clients reeducate themselves through a variety of techniques that facilitate changes in thoughts, perceptions, beliefs, and reactions to events. In effect, clients learn to replace the distorted or false cognitions that contributed to their addictions with more adaptive or realistic ones.

William A. Howatt, PhD, EdD, ICADC, a postdoc at the UCLA School of Medicine serves on the faculty at Nova Scotia Community College and is co-editor (with Robert H. Coombs) of the Wiley Book Series on Treating Addictions. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

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This article is published in Counselor,The Magazine for Addiction Professionals, February 2004, v.5, n.1, pp. 62-67.

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