On Alcohol/Substance Abuse: A positive Behavior Support perspective

One of the list-serves I regularly participate in had a discussion about how to address serious substance abuse and addictions from the perspective of Positive Behavior Support, when traumatic brain injury is also involved. A question came about appropriate replacement behavior and / reinforcers. I posted a response and got some very positive feedback on it, so I post it here as well:

I agree that NA/AA is helpful to many, though there are also many folks who are not amenable to the 12 step approach and/or the group process that is involved.
I have limited experience with individuals who have both brain injury and substance abuse issues, but I have observed that chronic substance abuse is often more of a negative reinforcement situation...that is, it is about escape from or avoidance of uncomfortable/intolerable emotions, memories and thoughts. In that sense it often begins as a form of self-medication, though it then may become a serious complicating challenge.

In such a situation, appropriate replacement behaviors would be those behaviors (for that individual) that might also help that person escape, manage or resolve the anxiety or negative emotions that they experience. 12 step programs and various forms of therapy may be useful in addressing the physical addiction and even treating some conditions such as underlying depression, trauma, social isolation, etc. However, I'm not sure that any therapeutic program itself should be viewed as an effective replacement behavior (other than very short term). Rather, it is a means to establish replacement behaviors.

Finding actual replacement behaviors will be more about tapping into the person's intrinsic motivational system and his/her strengths to identify and support life activities that are meaningful, that help manage emotional stress, and that lead to a sense of comfort, belonging and self-efficacy.

A healthy exercise regimen, meaningful social and recreational activities, activities that relax (yoga, meditation, relaxation techniques, biofeedback may help), and positive activities that are highly motivating to the individual may all serve as replacement behaviors that help to constructively manage emotional and cognitive stress over time. I believe that the most powerful replacement behaviors, as a rule, are those that fit the specific person (person centered) and that contribute to long term quality of life.