Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities.

Contingency management (CM) interventions usually reinforce submission of drug-negative specimens, but they can also reinforce adherence with goal-related activities. This study compared the efficacy of the 2 approaches. Substance-abusing outpatients (N = 131) were randomly assigned to 1 of 3 12-week treatments: standard treatment (ST), ST with CM for submitting negative urine toxicology screens, or ST with CM for completing goal-related activities. CM patients remained in treatment longer and achieved more abstinence than ST patients, but the CM condition that reinforced submission of negative samples resulted in better outcomes than the CM condition that reinforced goal-related activities. Abstinence at 6- and 9-month follow-ups did not differ by group, but longest duration of abstinence achieved during treatment was associated with abstinence posttreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy.

Objective: A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth. Method: A 2 × 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9–17 years included the Child Behavior Checklist and out-of-home placements. Results: A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%). Conclusions: Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interaction effects of age and contingency management treatments in cocaine-dependent outpatients.

As the American population ages, older adults are accounting for a larger percentage of the drug-abusing population, but little attention has been given to this age group especially in regards to evaluating responsivity to different treatment modalities. Contingency management (CM) is a highly effective behavioral treatment that provides positive tangible reinforcers for objective evidence of behavior change. The purpose of this study was to examine main and interactive effects of age on outcomes in cocaine-dependent patients receiving CM with standard care (SC) or SC alone. Patients (N = 393) participating in 1 of 3 randomized trials of CM for cocaine dependence were divided into young, middle, and older age cohorts. Baseline characteristics and outcomes were compared across the age groups. The oldest age group had more medical problems than the youngest and middle age groups but had fewer legal difficulties and psychiatric symptoms. The oldest age group remained in treatment significantly longer than the other age groups, regardless of the type of treatment received. Although all age groups benefited from CM in terms of retention and longest duration of abstinence achieved, a significant age by treatment interaction effect emerged, with the older cohort improving relatively less from CM than the younger age groups. These findings demonstrate that age may play a role in moderating intervention outcomes, and tailoring CM to the needs of older and middle-aged substance abusers may be important for improving outcomes in this growing population. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Statewide adoption and initial implementation of contingency management for substance-abusing adolescents.

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cultural adaptation of treatments: A resource for considering culture in evidence-based practice.

There is a growing interest in whether and how to adapt psychotherapies to take into account the cultural, linguistic, and socioeconomic context of diverse ethnocultural groups. At the root of the debate is the issue of whether evidence-based treatments (EBTs) developed within a particular linguistic and cultural context are appropriate for ethnocultural groups that do not share the same language, cultural values, or both. There is considerable evidence that culture and context influence almost every aspect of the diagnostic and treatment process. Yet, there are concerns about fidelity of interventions, and some have questioned whether tinkering with well-established EBTs is warranted. We present arguments in favor of the cultural compatibility and universalistic hypotheses. Next, we review the available published frameworks for cultural adaptations of EBTs and offer examples from the literature on the process and outcome of different approaches used. Conceptual models for adapting existing interventions and emerging evidence that adapted intervention leads to positive outcomes suggest that there are tools for engaging in evidence-based psychological practices with ethnocultural youth. Recommendations for future directions are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to 1 of the following 52-week interventions: (a) usual care only (UC), (b) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (c) take-home methadone doses for cocaine- and opiate-negative results and monetary-based vouchers contingent on cocaine-negative urinalysis results (THM + V). Cocaine use was assessed by urinalysis on a thrice-weekly schedule. Frequency and enjoyability of non-drug-related activities were assessed with the Pleasant Events Schedule (PES) at baseline, midtreatment, and end of treatment. The THM + V condition achieved the greatest abstinence from cocaine and opiate use, followed by the THM and UC conditions. The THM + V condition had the highest PES frequency ratings at midtreatment and at the end of treatment, followed by the THM and UC conditions. There were significant differences between the THM + V and UC conditions on 10 of 12 PES-derived subscales. Analyses revealed that abstinence mediated the effects of treatment condition on frequency ratings. There were no significant differences in enjoyability ratings. These results suggest that when contingency-management interventions increase abstinence from drug abuse, they also increase engagement in non-drug-related activities in naturalistic settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Low-cost contingency management in community clinics: Delivering incentives partially in group therapy.

This study examined the feasibility and effectiveness of prize-based contingency management (CM) when incentives for attendance were administered in group therapy and incentives for abstinence were administered in individual meetings. Three community substance abuse treatment programs participated in this two-phase, crossover design study. Outpatients (N = 103) entering treatment who met diagnostic criteria for cocaine, opiate, and alcohol abuse or dependence were recruited. During the standard condition, participants received standard treatment and submitted breath and urine samples that were tested for alcohol, cocaine, and opiates twice weekly during Weeks 1-6 and once weekly during Weeks 7-12. During the CM condition, participants received the same standard treatment and sample and attendance monitoring, plus the opportunity to win prizes for negative samples and treatment attendance. Demographic information and substance abuse history were evaluated at intake, and posttreatment substance use (toxicology results and self-report) was evaluated at Month 6 and Month 9 follow-up interviews. Primary outcomes were weeks retained in treatment and longest duration of sustained abstinence (LDA). LDA was significantly greater in CM-condition participants, but weeks retained did not differ between groups. Rates of substance use were lower in CM participants at Month 9 but not at Month 6. This study suggests that it is feasible to deliver incentives for attendance in group therapy, but that further research is needed to understand the modest effects on attendance. Strengths and limitations of this study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dissemination and implementation of evidence-based psychological treatments: A review of current efforts.

Recognizing an urgent need for increased access to evidenced-based psychological treatments, public health authorities have recently allocated over $2 billion to better disseminate these interventions. In response, implementation of these programs has begun, some of it on a very large scale, with substantial implications for the science and profession of psychology. But methods to transport treatments to service delivery settings have developed independently without strong evidence for, or even a consensus on, best practices for accomplishing this task or for measuring successful outcomes of training. This article reviews current leading efforts at the national, state, and individual treatment developer levels to integrate evidence-based interventions into service delivery settings. Programs are reviewed in the context of the accumulated wisdom of dissemination and implementation science and of methods for assessment of outcomes for training efforts. Recommendations for future implementation strategies will derive from evaluating outcomes of training procedures and developing a consensus on necessary training elements to be used in these efforts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of multisystemic therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders.

Objective: Although current evidence suggests that the positive effects of multisystemic therapy (MST) on serious crime reach as far as young adulthood, the longer term impact of MST on criminal and noncriminal outcomes in midlife has not been evaluated. In the present study, the authors examined a broad range of criminal and civil court outcomes for serious and violent juvenile offenders who participated on average 21.9 (range = 18.3–23.8) years earlier in a clinical trial of MST (C. M. Borduin et al., 1995). Method: Participants were 176 individuals who were originally randomized to MST or individual therapy (IT) during adolescence and averaged 3.9 arrests for felonies prior to treatment. Arrest, incarceration, and civil suit data were obtained in middle adulthood when participants were on average 37.3 years old. Results: Intent-to-treat analyses showed that felony recidivism rates were significantly lower for MST participants than for IT participants (34.8% vs. 54.8%, respectively) and that the frequency of misdemeanor offending was 5.0 times lower for MST participants. In addition, the odds of involvement in family-related civil suits during adulthood were twice as high for IT participants as for MST participants. Conclusions: The present study represents the longest follow-up to date of an MST clinical trial and demonstrates that the positive impact of an evidence-based youth treatment such as MST can last well into adulthood. Implications of the authors' findings for policymakers and service providers are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Investigating the pharmacological and nonpharmacological factors that modulate drug reinforcement.

Drug use is driven by principles of reinforcement and is sensitive to influences in the environmental context in which it occurs. Although a wide range of factors has been shown to directly influence the reinforcing effects of commonly abused drugs, 2 general types include pharmacological and nonpharmacological factors. Both can assert a powerful impact on a drug's reinforcing effects and, therefore, the degree to which a particular drug comes to be used and abused. This invited review seeks to briefly describe some of the current psychopharmacology research on the interactions between these factors and drug abuse. Several pharmacological influences on drug use will be discussed, including the interactions between psychomotor stimulants and recent advances in the development of pharmacotherapies for opioid abuse. With regard to nonpharmacological factors, there is a large body of research demonstrating that nondrug reinforcers can exert a powerful influence on the reinforcing effects of commonly abused drugs. More specifically, identifying alternative nondrug sources of reinforcement can, if made available contingent on drug abstinence, produce robust decreases in drug self-administration. Presented here is a very brief review of some recent scientific efforts to develop and extend behavioral interventions targeting drug use across a wide range of clinical populations. In summary, understanding the interactions among the variables present in the context of drug use is critical to understanding risk factors for substance use disorders as well as developing efficacious treatments for drug dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically guided coordination of multiple evidence-based treatments: An illustration of relevance mapping in children's mental health services.

Objective: Despite substantial progress in the development and identification of psychosocial evidence-based treatments (EBTs) in mental health, there is minimal empirical guidance for selecting an optimal set of EBTs maximally applicable and generalizable to a chosen service sample. Relevance mapping is a proposed methodology that addresses this problem through structured comparison of client characteristics in a service sample to participant characteristics from studies of EBTs. Method: The authors demonstrate the feasibility of relevance mapping using data from 1,781 youths in a statewide mental health system and a study data set including 437 randomized clinical trials. Relevance mapping (a) reveals who is “coverable” by any EBT, under different definitions of matches between study participants and clients, and (b) identifies minimum sets of treatments needed to serve maximum numbers of clients, across different levels of analysis for defining treatment operations. Results: In the illustration sample, all problems targeted by the study data set review were fully coverable when matching only required clients to have the same problem as EBT study participants. At the other extreme, when matching also required age, gender, ethnicity, and setting, the percentage of noncoverable youths increased to 86% in this sample. Two minimal sets of only 8 EBTs were identified that, when added to the one EBT already in place in that system, covered 100% of coverable youths when matching required problem, age, and gender. Conclusions: This methodology offers promise for the empirically guided selection and coordination of EBTs, thereby addressing one aspect of the gap between knowledge and practice. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Meta-analyses and systematic reviews of psychological treatments for chronic pain: Relevance to an evidence-based practice.

As evidence-based practitioners become more reliant on systematic reviews to inform treatment, it becomes important to systematize reporting details as well as improve the quality of the primary studies that will later be incorporated into this secondary literature. In this article, the authors consider several specific factors that can serve this function in the area of chronic pain: (a) adhering to a standardized set of reporting standards; (b) measuring a standardized set of short- and long-term outcome variables; (c) providing information about individual differences; and (d) providing detailed, easily accessible documentation of the treatment program (or progams). The article also highlights ways that practitioners and researchers can collaborate on treatment outcome research, thereby improving the ability to discover and disseminate effective treatments for patients who suffer from chronic pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of contingency management delivered in the context of group counseling.

Objective: Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. Method: Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. Results: Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. Conclusions: These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Multidimensional family therapy for young adolescent substance abuse: Twelve-month outcomes of a randomized controlled trial.

Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n = 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age = 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d = 0.77; substance use problems, d = 0.74), delinquency (d = 0.31), and internalized distress (d = 0.54), and in reducing risk in family, peer, and school domains (d = 0.27, 0.67, and 0.35, respectively) among young adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Manual-guided cognitive-behavioral therapy training: A promising method for disseminating empirically supported substance abuse treatments to the practice community.

A gap exists between empirically supported substance abuse treatments and those used in community settings. This study examined the feasibility of training substance abuse counselors to deliver cognitive-behavioral treatment (CBT) using treatment manuals. Participants were 29 counselors. Counselors were randomly assigned to receive CBT training or to a control group. Counselor attitudes were assessed pre- and posttraining. In addition, CBT therapy sessions were videotaped and rated for adherence and skillfulness. CBT counselors reported high levels of satisfaction with the training , intention to use CBT interventions, and confidence in their ability to do so. Ratings indicated that 90% of counselors were judged as having attained at least adequate levels of CBT skillfulness. Findings demonstrate the feasibility of using psychotherapy technology tools as a means of disseminating science-based treatments to the substance abuse practice community. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group-based randomized trial of contingencies for health and abstinence in HIV patients.

Objective: Contingency management (CM) treatments are usually applied individually for drug abstinence, but CM can also be targeted toward health behaviors and implemented in groups. This study evaluated effects of a group-based CM intervention that focused on reinforcing health behaviors. Method: HIV-positive patients with cocaine or opioid use disorders (n = 170) were randomized to weekly CM or 12-step (TS) groups for 24 weeks (mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 session for TS participants). During the treatment period, both groups received compensation for attendance ($10 per session) and submission of urine samples (about $2 per sample). In addition, participants received $25 for submitting samples and completing evaluations at Months 1, 3, 6, 9, and 12; 65–75 of the 81 participants assigned to TS and 71–80 of the 89 participants assigned to CM completed these evaluations. During the treatment period, patients in the CM group received chances to win prizes contingent upon completing health activities and submitting substance-free specimens (M = $260, SD = $267). Results: Mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 sessions for TS participants. CM participants submitted a significantly greater number of consecutive drug-free specimens than did TS participants (5.2 ± 6.0 vs. 3.7 ± 5.6), but proportions of negative samples did not differ between groups during treatment or at follow-up evaluations. From pre- to posttreatment, CM participants showed greater reductions in viral loads and HIV-risk behaviors than did TS participants, but these effects were not maintained throughout the follow-up period. Conclusions: These data suggest the efficacy of group-based CM for HIV-positive substance abusers, but more research is needed to extend the long-term benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized control trial examining the effect of acceptance and commitment training on clinician willingness to use evidence-based pharmacotherapy.

This study evaluated the effectiveness of acceptance and commitment training (ACT) for increasing drug and alcohol counselors' willingness to use evidence-based agonist and antagonist pharmacotherapy. Fifty-nine drug and alcohol counselors were randomly assigned to either a 1-day ACT workshop or a 1-day educational control workshop. Both groups then attended a 2-day workshop on empirically supported treatments for substance abuse. Measures were taken at pre- and posttraining and 3-month follow-up on reported use of pharmacotherapy, willingness to use pharmacotherapy, perceived barriers to implementing new treatments, and general acceptance. As compared with those in the education alone condition, participants in the ACT condition showed significantly higher rates of referrals to pharmacotherapy at follow-up, rated barriers to learning new treatments as less believable at posttraining and follow-up, and showed greater psychological flexibility at posttraining and follow-up. Mediational analyses indicated that reduced believability of barriers and greater psychological flexibility mediated the impact of the intervention. Results support the idea that acceptance-based interventions may be helpful in addressing the psychological factors related to poor adoption of evidence-based treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Current treatments for bipolar disorder: A review and update for psychologists.

Practicing psychologists are likely to be confronted with the diagnostic and treatment challenges associated with bipolar disorder, particularly the various classes of medication currently used in pharmacotherapy for the disorder. Although lithium remains a valuable resource, limitations associated with its use have prompted clinicians and researchers to explore the application of several different classes of agents, including anticonvulsants, calcium channel blockers, atypical antipsychotics, benzodiazepines and antidepressants, to the acute and long-term management of bipolar disorder. A review of these agents, as well as a summary of various psychotherapeutic modalities that can serve as adjunctive interventions to pharmacotherapy, is provided for psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up.

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)