Incentives for Sobriety
Stephen T. Higgins, Ph.D., and Nancy M. Petry, Ph.D.
Contingency management (CM), the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors, is an effective strategy in the treatment of alcohol and other drug (AOD) use disorders. Animal research provides the conceptual basis for using CM in AOD abuse treatment, and human studies have demonstrated the effectiveness of CM interventions in reducing AOD use; improving treatment attendance; and reinforcing other treatment goals, such as complying with a medication regimen or obtaining employment. KEY WORDS: addiction care; treatment method; intervention; reinforcement; treatment outcome; AOD (alcohol and other drug) abstinence; problematic AOD use; multiple drug use; AOD dependence; treatment goals; treatment research; patient compliance; employment; animal model; literature review
ontingency management (CM)1 through written contracts that detail CM. Within the CM framework, AOD is a strategy used in alcohol and the desired behavior change, duration use is considered a form of operant Cother drug (AOD) abuse treat- of intervention, frequency of monitoring, behavior—that is, behavior that is main- ment to encourage positive behavior and potential consequences of the patient’s tained in part by the reinforcing biochem- change (e.g., abstinence) in patients by success or failure in making the agreed- ical effects of the abused substance and providing reinforcing consequences when upon behavior changes. by reinforcing environmental influences patients meet treatment goals and by An extensive body of research sup- (e.g., social reinforcement from peers). withholding those consequences or pro- ports CM’s efficacy in treating various viding punitive measures when patients behavioral disorders, including AOD engage in the undesired behavior (e.g., abuse (Higgins and Silverman 1999; STEPHEN T. H IGGINS, PH.D., is a profes- drinking). For example, positive conse- Higgins et al. 1998). This article briefly sor in the Departments of Psychiatry and quences for abstinence may include reviews the conceptual background and Psychology at the University of Vermont, receipt of vouchers that are exchange- empirical research demonstrating the Burlington, Vermont. able for retail goods, whereas negative efficacy of CM in AOD abuse treatment. consequences for drinking may include NANCY M. PETRY, PH.D., is an assistant withholding of vouchers or an unfavor- professor in the Department of Psychiatry able report to a parole officer. The rein- Conceptual and Basic at the University of Connecticut School of forcing or punishing consequences may Science Foundations Medicine, Farmington, Connecticut. be contingent on objective evidence of recent AOD use or on another behavior The use of reinforcing and punishing Preparation of this article was supported important in the treatment process, such consequences to alter the form and fre- in part by Federal grants RO1–DA09378 as compliance with a medication regimen quency of voluntary behavior is known (S.T.H.), RO1–DA0-8076 (S.T.H.), or regular clinic attendance. Often, as operant conditioning, a method that R29–DA12056 (N.M.P.), and P50–AA0- clinicians implement CM procedures provides the conceptual framework for 3510 (N.M.P.).
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Findings from animal research support exposed to alcohol, rats bred for high substances, an increase in the availability the use of CM in the treatment of AOD alcohol intake will voluntarily consume of alternative reinforcers will decrease use disorders. Such research demonstrates, larger amounts of alcohol than non- AOD consumption. Furthermore, for instance, that animals exhibit con- selectively bred rats. However, even ini- increasing the demands required to obtain sumption patterns indicative of depen- tially low-alcohol-consuming rats will the desired substance (e.g., increasing dence and that researchers can modify voluntarily consume large quantities of the number of times an animal must animals’ AOD intake by using reinforcing alcohol under certain conditions. For press a lever to obtain the alcohol) or and punishing consequences. Generally, directly associating substance use with laboratory animals voluntarily ingest the loss of other desired goods (e.g., the same substances that humans abuse withholding vouchers as a consequence (Griffiths et al. 1980). Rats and monkeys, CM interventions of alcohol use) reduces AOD use as for example, will voluntarily consume well (Higgins 1996). large quantities of cocaine, opioids, and are based on the CM interventions are based on the alcohol. Neither a prior history of drug view that AOD use view that AOD use is a behavior that exposure nor physical dependence is is influenced by neurobiological and necessary to support ongoing and stable is a behavior that environmental factors and that such patterns of AOD use in laboratory ani- behavior can be changed by applying mals. Moreover, studies of voluntary is influenced by consistent environmental consequences AOD consumption by laboratory animals neurobiological and to reinforce the targeted behavior change. show that once a pattern of heavy con- The following sections of this article sumption has been established, animals environmental factors. describe research on the application of will complete cumbersome tasks (e.g., CM in the treatment of alcoholism and press a lever numerous times) to obtain problem drinking as well as of other and consume the desired substance. example, stress, social isolation, and drug use disorders. Additionally, laboratory animals will reduced access to food, liquid, or oppor- forgo other reinforcers, including sweet tunities for exercise all promote AOD liquids, high-calorie solutions, and in use in laboratory animals. Therefore, Early Research and some cases even basic sustenance, to susceptibility to the reinforcing effects Application of CM engage in AOD use (Petry and Heyman of AODs appears to be a product of in the Treatment of 1995). These behavioral patterns are normal neurobiological systems common Problem Drinking analogous to those exhibited by AOD- to many species that can be heightened dependent humans, who often spend by certain individual and environmen- Research during the 1960s, 1970s, and significant amounts of time and money tal factors. 1980s examined the role of CM in abusing alcohol and recovering from Findings from animal studies may alcoholism treatment as a strategy for AOD use, and who often give up recre- have implications for human AOD reinforcing abstinence as well as accom- ation, employment, and family activities abuse treatment in that the environmen- plishing other treatment goals, including to do so. tal conditions which promote AOD medication compliance and treatment These findings—that laboratory ani- use in laboratory animals seem similar attendance. mals voluntarily consume many of the to those associated with excessive AOD same substances that humans abuse and use in humans (Griffiths et al. 1980). Reinforcement of Abstinence exhibit consumption patterns indicative Animal studies also demonstrate that of dependence—suggest that the neces- conditions can be altered to reduce AOD In an early study of CM in alcoholism sary neurobiological systems to experi- use even after high levels of use have treatment, Miller (1975) found that by ence AOD-induced reinforcement and been established. Such studies suggest providing tangible reinforcers to public to engage in compulsive AOD use are that an increase in both the availability inebriates, contingent on negative widely represented across different species. of alternative, nondrug sources of rein- breath-alcohol tests, researchers could However, laboratory studies also indi- forcement and the direct and indirect effectively reduce public inebriation. cate that individual and environmental losses associated with AOD use are In the study, 20 public inebriates were factors clearly influence susceptibility to related to decreased AOD use (Higgins randomly assigned to one of two groups: AOD use and abuse (Wolffgramm and 1996). For example, providing food, a contingent group or a noncontingent Heyne 1995). For example, when first liquids, or novel environmental alterna- group. A person in the contingent group tives reduces AOD use in animals, just received shelter, employment, food, and as providing entertainment or financial clothing from local social services agencies 1Editor’s Note: Community-reinforcement alternatives reduces AOD use in humans. only when he or she remained sober. approach (CRA), a treatment methodology that Although, as previously noted, animals Members of the noncontingent group uses strategies similar to those used in CM, is discussed in a separate article in this issue by Miller and humans will work hard or forgo received social services regardless of et al., pp. 116–121. other reinforcers to consume addictive their drinking behavior. The researchers
Vol. 23, No. 2, 1999 123 assessed sobriety by conducting random During the 6-month treatment treatment sessions. Gallant and col- breath-alcohol tests and through staff period, patients in the contingent group leagues (1968b) found beneficial effects observation. When the researchers de- drank, on average, on only 2 percent in making treatment attendance a con- tected alcohol use in a contingent group of the total number of days, compared dition of parole among alcoholics recently member, they immediately suspended with an average of 21 percent for the released from 1-year or longer sentences his or her social services for 5 days. control group. In addition, a controlled for major alcohol-related offenses. In During the 2-month treatment period, case study suggested that a CM inter- the study, the researchers randomly the contingent group’s arrest rate for assigned 19 alcoholics to either outpa- public drunkenness decreased from an tient treatment at which attendance average of 1.7 arrests per 2 months to was a parole requirement or outpatient an average of 0.3 arrests per 2 months. Several studies treatment at which attendance after the Conversely, the noncontingent group’s first appointment was urged but not arrest rate showed little change, decreas- have demonstrated required. For parolees in the first group, ing from an average of 1.4 arrests per 2 the efficacy of failure to attend treatment resulted in a months to an average of 1.3 arrests per return to prison to serve the remainder 2 months. In addition, members of the CM in reducing of their sentence. Ninety percent of contingent group increased their aver- drinking and this group attended treatment regularly age number of hours of employment for 6 months, compared with only 11 over the study period, an effect that was increasing treatment percent of the voluntary treatment not found in the noncontingent group. group. After 1 year, 70 percent of the Additional studies of CM have compliance. contingent group was abstinent and also indicated positive findings. For working, whereas 78 percent of the example, researchers have reported pos- voluntary treatment group was either itive outcomes using CM to reinforce vention involving supervised disulfiram in prison or had violated parole. abstinence among adolescent alcohol ingestion was effective in reducing absen- In another application of CM in the abusers (Brigham et al. 1981) and teeism among employees referred for criminal justice system, Ersner-Hershfield among alcohol-abusing schizophrenics drinking on the job (Robichaud et al. and colleagues (1981) evaluated the use (Peniston 1988). 1979). of contingencies to promote treatment Another study of similar CM proce- attendance among offenders convicted Reinforcement of Medication dures conducted with public drunken- of driving under the influence (DUI). Compliance ness offenders found no positive effect. Sixty-seven DUI offenders were randomly Gallant and colleagues (1968a) randomly assigned to either a program based on In addition to the direct reinforcement assigned 84 repeat public drunkenness behavioral self-control or a program of abstinence, CM also has been used to offenders to one of four 6-month treat- consisting of alcohol education, relax- reinforce compliance with medications ments: (1) mandated group therapy, ation training, and guided re-evaluations prescribed to reduce drinking, such as (2) mandated group therapy plus thrice of situations associated with drinking disulfiram (Antabuse®). Patients taking weekly observed disulfiram ingestion, and driving. One-half of the offenders disulfiram have severe adverse reactions (3) thrice weekly observed disulfiram in each group participated in a deposit to alcohol and are therefore unlikely to ingestion only, and (4) the usual sen- system in which they paid $50 at the drink when taking the medication. tence as well as an informal suggestion first session and received a $5 reimburse- Liebson and colleagues (1978) randomly to attend an alcoholism clinic. In the ment check for each subsequent session assigned 23 alcoholics who were receiv- first three groups, noncompliance was that they attended. The two treatments ing methadone for heroin dependence intended to result in an automatic 60- were equally effective; however, partici- to either a contingent or control group. day sentence. Contingencies were not pants in the refundable-deposit groups In the contingent group, each patient’s consistently applied, however, and no had fewer unexcused absences than continued methadone treatment was differences were noted between the patients in the no-deposit groups. contingent on the patient’s ingestion of groups. This lack of effect may be related, As described above, several studies disulfiram. Patients who did not take in part, to the fact that fewer than 10 have demonstrated the efficacy of CM the mandatory doses of disulfiram had percent of the study participants were in reducing drinking and increasing their daily dose of methadone reduced available for the 6-month posttreat- treatment compliance among alcoholics until it reached zero and they were dis- ment evaluation. and problem drinkers. Studies that did continued from the program or until not report positive effects were hindered they began or resumed taking disulfi- Reinforcement of Treatment by inconsistent monitoring and appli- ram. In the control group, disulfiram Attendance cation of consequences, which may therapy was recommended, but non- account for the poor outcomes (Gallant compliance had no effect on continued CM also has been used in alcoholism 1968a). Until recently, research on the methadone treatment. treatment to encourage patients to attend use of CM to treat problem drinking
124 Alcohol Research & Health Contingency Management: Incentives for Sobriety
ceased, whereas CM research flourished and sometimes a punishment (i.e., the Based on these findings and similar in the area of illicit and polydrug abuse voucher amount decreased to a lower results from other studies, the National treatment. Those developments are value or loss of take-home privileges). Institute on Drug Abuse published a described below. Research indicates that AOD abuse therapy manual detailing how to imple- treatments incorporating CM are more ment this treatment with cocaine- Expansion and Further effective than standard case management, dependent outpatients, including the Development of CM Procedures 12-step-oriented counseling, and behav- sizable subgroup who are also alcohol ior therapies delivered without a CM dependent (Budney and Higgins 1998). Recent CM interventions have been component (Higgins and Silverman Silverman and colleagues (1996) structured around four central principles. 1999; Petry et al. in press). CM inter- further investigated the use of a voucher- First, the clinician arranges for regular ventions generally retain patients in based incentive program among inner- testing to ensure that the patient’s use of treatment longer and reduce AOD use city intravenous cocaine abusers. The the targeted substance is readily detected. more than do comparison treatments researchers randomly assigned cocaine- Second, the clinician provides agreed- or other comparison conditions. In a abusing methadone patients either to upon tangible reinforcers when absti- study with 38 cocaine-dependent adults, receive vouchers contingent on submis- nence is demonstrated. Third, the clini- for example, researchers randomly sion of cocaine-free urine specimens cian withholds the designated incentives assigned patients to 24 weeks of com- (i.e., contingent group) or to receive from the patient when substance use is munity reinforcement approach (CRA) vouchers regardless of drug test results detected. Fourth, the clinician assists therapy, an operant-based treatment (i.e., noncontingent group). Members the patient in establishing alternate and methodology originally developed to of the noncontingent group received, healthier activities (e.g., a better paying treat chronic alcoholics (see the article on average, the same overall number of job, improved family relations, enjoy- in this issue by Miller et al., pp. 116–121, vouchers as patients in the contingent able social and recreational activities) to for more details), as well as CM or 12- group, and both groups were retained compete with the reinforcement derived step-oriented counseling (Higgins et al. in treatment for similar durations. Forty- from the AOD-abusing lifestyle. CM is 1993). In the CM condition, patients seven percent of the clients in the con- usually, but not always, included as part received vouchers for submitting cocaine- tingent group tested negative for cocaine of a comprehensive treatment plan negative urine specimens. Fifty-eight for 6 or more consecutive weeks, com- involving other psychosocial and phar- percent of patients in the CM condi- pared with only 6 percent of those in macological interventions. tion remained in treatment throughout the noncontingent group, thereby fur- the study, compared with 11 percent ther demonstrating the utility of CM of patients in the comparison group. for reducing cocaine use even in this CM in Illicit and Polydrug CRA plus CM was effective in reduc- difficult-to-treat population. Other Abuse Treatment ing cocaine use as well. Sixty-eight per- randomized, controlled studies with cent of clients in the CM condition opioid-dependent patients have shown Clinicians have used CM in illicit drug maintained at least 8 weeks of continu- that providing money, voucher incentives, abuse treatment to reinforce abstinence ous cocaine abstinence, compared with or clinic privileges contingent on objective as well as other treatment-related behav- 11 percent of patients in the compari- indicators of drug abstinence can reduce iors, such as treatment attendance or son group. illicit drug use (Higgins et al. 1998). compliance with a medication regimen. In the aforementioned study, two aspects of treatment varied between Reinforcing Other Treatment- Reinforcement of Abstinence groups: provision of contingencies and Related Goals orientation of therapy. A subsequent In many CM interventions involving study demonstrated the contribution of A few recent studies among illicit drug illicit drug abusers, clients submit urine CM to the beneficial effects observed users have evaluated the use of CM specimens several times weekly to be (Higgins et al. 1994). Again, researchers procedures to reinforce not only absti- screened for evidence of drug use. When randomly assigned cocaine-dependent nence but also other treatment goals the specimens are negative for drug use, adults to one of two conditions: CRA (Bickel et al. 1997; Iguchi et al. 1997). clients receive reinforcers, such as take- therapy plus CM using vouchers or For example, in a study of opioid- home doses of methadone, increases in CRA therapy alone. Seventy-five per- dependent clients, therapists used clinic privileges, money, and vouchers cent of the patients who received CRA vouchers to reinforce beneficial, non- exchangeable for retail goods. In many plus CM completed the 24-week study, drug-related activities in addition to of the CM studies that use vouchers as compared with 40 percent of the patients abstinence (Bickel et al. 1997). Clients reinforcers, the value of the earned who only received CRA therapy. Fifty- chose three treatment-related activities vouchers escalates as the patient demon- five percent of the patients in the CM that they aimed to complete each week. strates consecutively longer periods of group achieved at least 2 months of Such activities included attending a abstinence. Submission of samples show- continuous cocaine abstinence, compared medical appointment if the goal was ing drug use results in no reinforcer with 15 percent of the comparison group. to improve health, taking their child
Vol. 23, No. 2, 1999 125 to the library if the goal was to improve compared with only 22 percent of the proper implementation is important. parenting, or applying for a job if the patients in the standard treatment group. In particular, treatment staff should goal was to obtain employment. Patients By the end of the treatment period, 69 monitor patients frequently and provide received vouchers when they presented percent of the patients in the contingent reinforcers consistently. Future research documentation verifying that they had group had not yet experienced a relapse may need to focus on staff training to completed a designated activity. Patients to alcohol use, compared with 39 percent increase the consistency with which who completed their chosen activities of the patients in the standard treat- reinforcers are applied, especially as CM were more likely to remain abstinent ment group. These results suggest that is used in non-research-based settings. than those who did not meet their activity this CM procedure, which reinforced The use of CM in alcoholism treat- goals. Reinforcing compliance with both abstinence and compliance with ment may be limited, however, by the treatment-related activities may encour- other treatment goals, was effective in technology available to test for alcohol age patients to acquire new skills and retaining alcohol-dependent patients in use. Most CM interventions targeting overcome psychosocial difficulties associ- treatment and reducing relapse. drug abstinence screen patients’ urine ated with their AOD abuse. This Researchers are currently developing specimens several times weekly. Because approach is somewhat analogous to CRA. a project specifically designed to simul- most drug-testing procedures can detect taneously reinforce abstinence and pro- drug use over a 2- to 3-day period, twice vide skills development in patients or thrice weekly monitoring can detect CM in the Treatment (Silverman, K., personal communication, any drug use throughout the week. of Problem Drinking January 1999). Chronically unemployed, However, alcohol testing is less sensitive. and Alcoholism homeless alcoholics will be randomly Breath alcohol tests can only determine assigned to one of three groups. Members whether a person has consumed alcohol After a relatively long hiatus, researchers of the first group will receive data entry over the past 4 to 12 hours; thus, the have again begun studying the use of training and paid employment, but submission of negative samples confirms CM in alcoholism treatment, partly they will only be allowed to work and abstinence for only a relatively brief time as an outgrowth of the recent research earn vouchers when they abstain from period. Alcohol urine tests cannot detect demonstrating its efficacy with illicit alcohol use. The second group will use over a much longer time period than and polydrug abusers. receive data entry training and employ- can breath tests, and blood alcohol tests In a recent CM study, 42 alcohol- ment regardless of their alcohol use. are more invasive and still fail to extend dependent patients entering an intensive The third group will not receive either the time period over which alcohol use outpatient substance abuse clinic received training or employment but will receive can be detected. Researchers are evaluat- either standard treatment plus CM or vouchers regardless of alcohol use. This ing the use of biological markers, which standard treatment only (Petry et al. in study will evaluate CM’s efficacy in reflect the physiological changes that press). Standard treatment consisted of improving psychosocial functioning and occur in the body after alcohol use, to daily 5-hour group sessions focusing on in reducing alcohol use among one of detect both heavy and recent drinking relapse prevention, social and recreational the most difficult-to-treat populations. even after the breath alcohol level reaches training (i.e., planning alternative evening zero (Allen and Litten 1998). The tests activities), 12-step-oriented groups, and for such biological markers require the AIDS education. This treatment con- Conclusions and Future shipment of specimens to a laboratory tinued for 4 weeks, after which patients Directions for analysis and therefore cannot provide were transferred to aftercare. The after- immediate feedback, which is possible care component consisted of similar CM interventions among alcoholics, with some tests for illegal drugs. Thus, group sessions held 1 to 3 days per week. problem drinkers, and illicit-drug researchers face some fundamental prob- Patients in both groups (i.e., standard abusers have been found to be effective lems when designing CM interventions treatment plus CM or standard treat- in reducing AOD use; retaining to reduce drinking. As more studies ment only) provided breath samples to patients in treatment; improving medi- evaluate CM among alcohol-dependent test for alcohol use. These breath sam- cation compliance; and promoting par- populations, researchers will need to ples were submitted daily for the first ticipation in other treatment-related consider these technological difficulties. 4 weeks of treatment and then weekly goals, such as employment. The rein- In addition to the goal of abstinence, during the aftercare period. Patients in forcers used in these interventions have CM interventions also are being used the CM group earned the chance to win included special privileges, money, among alcohol-dependent clients to a prize for each negative breath sample methadone doses, vouchers, and prizes. reinforce other treatment-related goals, they submitted and for each of three Studies of CM across various patient such as treatment attendance and preset activities that they completed dur- populations that target various behaviors employment. This practice may pre- ing the week. The prizes ranged in value and use various reinforcers have found sent a more comprehensive approach from $1 to $100. Eighty-four percent that CM generally improves outcomes to treating AOD use disorders and may of the patients in the CM group remained relative to comparison treatments. improve patients’ psychosocial prob- in treatment for the entire 8-week period, Although CM is generally effective, lems. Future research is needed to fur-
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ther evaluate the efficacy of these and American Society of Addiction Medicine, Inc., HIGGINS, S.T.; BUDNEY, A.J.; BICKEL, W.K.; FOERG, related procedures. 1998. pp. 263–271. F.E.; OGDEN, D.; AND BADGER, G.J. Outpatient behavioral treatment for cocaine dependence: One- Followup studies on the efficacy of BICKEL, W.K.; AMASS, L.; HIGGINS, S.T.; BADGER, year outcome. Experimental and Clinical Psychopharm- G.J.; AND ESCH, R.A. Effects of adding behavioral CM have demonstrated beneficial acology 3:205–212, 1995. long-term effects but have also found treatment to opioid detoxification with buprenor- phine. Journal of Consulting and Clinical Psychology HIGGINS, S.T.; TIDEY, J.W.; AND STITZER, M.L. evidence of relapse in about the same 65:803–810, 1997. proportion as is seen with other psy- Community reinforcement and contingency manage- ment interventions. In: Graham, A.W.; Schultz, chological treatments for AOD abuse BRIGHAM, S.L.; REKERS, G.A.; ROSEN, A.C.; SWIHART, J.J.; PFRIMMER, G.; AND FERGUSON, L.N. Contingency T.K.; and Wilford, B.B., eds. Principles of Addiction disorders (Higgins et al. 1995). CM management in the treatment of adolescent alcohol Medicine. 2d ed. Chevy Chase, MD: American Society studies with larger numbers of partici- drinking problems. Journal of Psychology 109(1): of Addiction Medicine, Inc., 1998. pp. 675–690. pants are needed to more carefully 73– 85, 1981. IGUCHI, M.Y.; BELDING, M.A.; MORRAL, A.R.; quantify relapse rates with this treat- BUDNEY, A.J., AND HIGGINS, S.T. National Institute LAMB, R.J.; AND HUSBAND, S.D. Reinforcing operants ment approach. Further research is also on Drug Abuse Therapy Manuals for Drug Addiction: other than abstinence in drug abuse treatment: An needed to evaluate the optimal length Manual No. 2: A Community Reinforcement Plus effective alternative for reducing drug use. Journal Vouchers Approach: Treating Cocaine Addiction. NIH of Consulting and Clinical Psychology 65(3):421– of treatment with CM and the use of Pub. No. 98–4309. Rockville, MD: National 428, 1997. reinforcers to improve longer term out- Institute on Drug Abuse, 1998. comes. For example, treatment gains LIEBSON, I.A.; TOMMASELLO, A.; AND BIGELOW, ERSNER-HERSHFIELD, S.M.; CONNORS, G.J.; AND G.E. A behavioral treatment of alcoholic methadone may be maintained by improving the MAISTO, S.A. Clinical and experimental utility of transition from the use of more contrived refundable deposits. Behavioral Research and Therapy patients. Annals of Internal Medicine 89:342–344, reinforcers (e.g., vouchers) to more 19(5):455–457, 1981. 1978. naturally occurring reinforcers (e.g., GALLANT, D.M.; BISHOP, M.P.; FAULKNER, M.A.; MILLER, P.M. A behavioral intervention program obtaining and maintaining employment) SIMPSON, L.; COOPER, A.; LATHROP, D.; BRISOLARA, for chronic public drunkenness offenders. Archives as well as by altering reinforcement A.M.; AND BOSSETTA, J.R. A comparative evalua- of General Psychiatry 32(7):915–918, 1975. schedules from continuous reinforce- tion of compulsory (group therapy and/or Antabuse) and voluntary treatment of the chronic alcoholic PENISTON, E.G. Evaluation of long-term therapeu- ment during initial treatment to more municipal court offender. Psychosomatics 9(3):306– tic efficacy of a behavior modification program variable reinforcement schedules as the 310, 1968a. with chronic male psychiatric inpatients. Journal of treatment progresses. Behavior Therapy and Experimental Psychiatry 19:95– GALLANT, D.M.; FAULKNER, M.; STOY, B.; BISHOP, 101, 1988. Finally, CM may be well suited for M.P.; AND LANGDON, D. Enforced clinic treatment treating a variety of populations. Positive of paroled criminal alcoholics. Quarterly Journal of PETRY, N.M., AND HEYMAN, G.M. Behavioral eco- reinforcement procedures may effectively Studies on Alcohol 29:77–83, 1968b. nomics of concurrent ethanol-sucrose and sucrose reinforcement in the rat: Effects of altering variable- prevent alcohol use in high-risk adoles- GRIFFITHS, R.R.; BIGELOW, G.E.; AND HENNING- ratio requirements. Journal of the Experimental Analysis cents and pre-adolescents. Additionally, FIELD, J.E. Similarities in animal and human drug- of Behavior 64(3):331–359, 1995. these procedures may help encourage taking behavior. In: Mello, N.K., ed. Advances in Substance Abuse: Behavioral and Biological Research. PETRY, N.M.; MARTIN, B.; COONEY, J.; AND non-treatment-seeking patients to begin Vol. 1. Greenwich, CT: JAI Press, Inc., 1980. pp. KRANZLER, H.R. Give them prizes and they will alcoholism treatment. CM is not a 1–90. “magic bullet” for treating any group, come: Contingency management treatment of alco- HIGGINS, S.T. Some potential contributions of hol dependence. Journal of Consulting and Clinical however, and researchers must design reinforcement and consumer-demand theory to Psychology, in press. and implement CM interventions reducing cocaine use. Addictive Behaviors 21(6): carefully to ensure their effectiveness. 803–816, 1996. ROBICHAUD, C.; STRICKLER, D.; BIGELOW, G.; AND Nevertheless, these procedures offer the LIEBSON, I. Disulfiram maintenance employee alco- HIGGINS, S.T., AND SILVERMAN, K. Motivating holism treatment: A three-phase evaluation. Behavior opportunity for clinicians to effectively Illicit Drug Abusers to Change Their Behavior: Research Research and Therapy 17:618–621, 1979. manage and treat some of the most on Contingency Management Interventions. Washington, challenging problems and populations DC: American Psychological Association, 1999. SILVERMAN, K.; HIGGINS, S.T.; BROONER, R.K.; MONTOYA, I.D.; CONE, E.J.; SCHUSTER, C.R.; AND in the field of AOD abuse. HIGGINS, S.T.; BUDNEY, A.J.; BICKEL, W.K.; HUGHES, PRESTON, K.L. Sustained cocaine abstinence in J.R.; FOERG, F.; AND BADGER, G. Achieving cocaine abstinence with a behavioral approach. American methadone maintenance patients through voucher- Journal of Psychiatry 150(5):763–769, 1993. based reinforcement therapy. Archives of General References Psychiatry 53(3):409–415, 1996. HIGGINS, S.T.; BUDNEY, A.J.; BICKEL, W.K.; ALLEN, J., AND LITTEN, R.Z. Screening instruments FOERG, F.E.; DONHAM, R.; AND BADGER, G.J. WOLFFGRAMM, J., AND HEYNE, A. From controlled and biochemical screening tests. In: Graham, A.W.; Incentives improve outcome in outpatient behav- drug intake to loss of control: The irreversible devel- Schultz, T.K.; and Wilford, B.B., eds. Principles of ioral treatment of cocaine-dependence. Archives of opment of drug addiction in the rat. Behavioural Addiction Medicine. 2d ed. Chevy Chase, MD: General Psychiatry 51(7):568–576, 1994. Brain Research 70(1):77–94, 1995.
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