National Institute on Drug Abuse

RESEARCH

MONOGRAPH SERIES

Behavioral

Treatments for

Drug Abuse and

Dependence

U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health

137
Behavioral Treatments for

Drug Abuse and

Dependence

Editors:

Lisa Simon Onken, Ph.D.

Jack D. Blaine, M.D.

John J. Boren, Ph.D.

NIDA Research Monograph 137

1993

US. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857
ACKNOWLEDGMENT

This monograph is based on the papers from a technical review on

“Behavioral Treatments on Drug Abuse and Dependence” held in 1992.

The review meeting was sponsored by the National Institute on Drug

Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from the

copyright holders to reproduce certain previously published material as

noted in the text. Further reproduction of this copyrighted material is

permitted only as part of a reprinting of the entire publication or chapter.

For any other use, the copyright holder’s permission is required. All other

material in this volume except quoted passages from copyrighted sources

is in the public domain and may be used or reproduced without

permission from the Institute or the authors. Citation of the source is

appreciated.

Opinions expressed in this volume are those of the authors and do not

necessarily reflect the opinions or official policy of the National Institute

on Drug Abuse or any other part of the Department of Health and Human

Services.

The U.S. Government does not endorse or favor any specific commercial

product or company. Trade, proprietary, or company names appearing in

this publication are used only because they are considered essential in the

context of the studies reported herein.

National Institute of Drug Abuse

NIH Publication No. 93-3684

Printed 1993

NIDA Research Monographs are indexed in the Index Medicus. They are

selectively included in the coverage of American Statistics Index, Biosciences

Information Service, Chemical Abstracts, Current Contents, Psychological

Abstracts, and Psychopharmacology Abstracts.

ii
Contents

Page

Behavioral Treatments for Drug Abuse and Dependence:

Progress, Potential, and Promise . . . . . . . . . . . . . . . . . . . . . . . . . 1

Lisa Simon Onken, Jack D. Blaine, and John J. Boren

Advancing the Application of Behavioral Treatment

Approaches for Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . 5

Charles R. Schuster and Kenneth Silverman

Contingency Management in Methadone Treatment:

The Case for Positive Incentives . . . . . . . . . . . . . . . . . . . . . . . . 19

Maxine L. Stitzer, Martin Y. Iguchi, Michael Kidorf,

and George E. Bigelow

Clinicwide and Individualized Behavioral Interventions in

Drug Dependence Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

John Grabowski, Howard Rhoades, Ronith Elk,

Joy Schmitz, and Daniel Creson

Cue Reactivity and Cue Reactivity Interventions in

Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Anna Rose Childress, Anita V. Hole, Ronald N. Ehrman,

Steven J. Robbins, A. Thomas McLellan,

and Charles P. O’Brien

Treatment of Cocaine Dependence Through the Principles of

Behavior Analysis and Behavioral Pharmacology . . . . . . . . . . . . 97

Stephen T. Higgins and Alan J. Budney

Cognitive Therapy of Substance Abuse: Theoretical Rationale . . 123

Fred D. Wright, Aaron T. Beck, Cory F. Newman,

and Bruce S. Liese

Harm Reduction: Application to Alcohol Abuse Problems . . . . . 147

G. Alan Marlatt, Julian M. Somers, and Susan F. Tapert

iii
Behavioral Treatments for Drug Problems: Lessons

From the Alcohol Treatment Outcome Literature . . . . . . . . . . . . 167

William R. Miller

Multisystemic Treatment of Serious Juvenile Offenders:

Implications for the Treatment of Substance-Abusing Youths . . . 181

Scott W. Henggeler

Dialectical Behavior Therapy for Treatment of Borderline

Personality Disorder: Implications for the Treatment of

Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Marsha M. Linehan

Substance Abuse Research: Outcome Measurement Conundrums 217

Karla Moras

Between-Group Therapy Outcome Research: Design and

Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

T.D. Borkovec

When Clinical Trials Fail: A Guide to Disaggregation . . . . . . . 291

Kenneth I. Howard, Merton S. Krause, and John S. Lyons

Behavioral Treatments for Drug Problems:

Where Do We Go From Here? . . . . . . . . . . . . . . . . . . . . . . . . 303

William R. Miller

iv
Behavioral Treatments for Drug

Abuse and Dependence:

Progress, Potential, and Promise

Lisa Simon Onken, Jack D. Blaine, and John J. Boren

This monograph is a product of a National Institute on Drug Abuse

technical review meeting, “Behavioral Treatments for Drug Abuse and

Dependence,” held in Bethesda, Maryland, on September 1 and 2,

1992. The meeting was chaired by the editors of this monograph. The

participants included Drs. Thomas D. Borkovec, Anna Rose Childress,

John Grabowski, Scott W. Henggeler, Stephen T. Higgins, Kenneth I.

Howard, Marsha M. Linehan, G. Alan Marlatt, William R. Miller,

Karla Moras, Charles R. Schuster, Maxine Stitzer, and Fred Wright.

In the past decade, behavioral treatment researchers have explored the

efficacy of numerous behavioral interventions for drug dependent

individuals and have made considerable progress. Research studies on

behavioral treatments for drug dependence were presented by scientists

who do state-of-the-art research in this area: Drs. Stitzer, Childress,

Grabowski, and Higgins. In her presentation and in the chapter she

wrote with Drs. Iguchi, Kildorf, and Bigelow, Dr. Stitzer reviewed the

research on the use of positive versus negative contingencies with

methadone maintenance patients and presented the advantages of using

positive incentives. Cognitive therapy for substance abuse was clearly

described by Dr. Wright at the technical review and again in the

chapter written by Drs. Wright, Beck, Newman, and Liese. Dr.

Childress reviewed the work she has done on cue exposure with opiate

and cocaine addicts. In her chapter, she and her coauthors, Drs. Hole,

Ehrman, Robbins, McLellan, and O’Brien, alert the field to the need

for providing patients with active strategies for managing their drug

problems in addition to the passive cue exposure strategies used in the

laboratory. Dr. Grabowski pointed out that even when clinics do not

define them as such, all clinics use clinicwide behavioral interventions,

commonly thought of as the rules of the clinic. Dr. Grabowski and his

coauthors, Drs. Rhoades, Elk, Schmitz, and Creson, reviewed the ways

in which these clinicwide and individualized contingencies can impact

1
positively on drug dependence treatment. Dr. Higgins showed how

community reinforcement, an approach that controls and utilizes

reinforcers in multiple aspects of the cocaine-dependent individual’s

life, can increase the ability to achieve and maintain cocaine

abstinence. Dr. Higgins’ approach, described in the chapter by

Drs. Higgins and Budney and originally developed by Hunt and Azrin

(1973) for use with alcoholics, holds great promise for the treatment of

cocaine addiction. The work of the fine behavioral treatment

researchers at the technical review has, in many ways, set the standard

for behavioral drug dependence treatment research.

Significant progress has been made in the past 20 years in alcoholism

treatment. As Dr. Higgins has shown, some of the treatments known

to work well for alcoholics may work well for persons addicted to

other drugs. Familiarity with the literature on behavioral treatments

for alcohol dependence can greatly improve our ability to develop

effective treatments for drug dependence. The research on behavioral

treatments for alcohol dependence has been comprehensively reviewed

by Dr. Miller and is a significant contribution to this monograph. In

the same spirit, Dr. Marlatt and his colleagues, who are alcoholism

behavioral treatment researchers, have written a piece on harm

reduction. Their perspective challenges the conventional wisdom

regarding drug dependence treatment (i.e., that anything short of

complete drug abstinence is a failure). Whether or not one agrees,

unconventional perspectives may provide an impetus for framing a

problem in a different way, ultimately leading to new approaches

toward solving problems. The editors hope and believe that the

contributions made to this monograph will spark new ideas regarding

the behavioral treatment of drug dependence.

Dr. Henggeler presented his research findings on the treatment of

antisocial adolescents with multisystemic therapy. Dr. Linehan has

developed dialectical behavior therapy for parasuicidal individuals who

meet criteria for borderline personality disorder. Both Dr. Henggeler’s

and Dr. Linehan’s populations are well known for being difficult to

treat. Both populations are also well known for their substantial

comorbid drug dependence problems. The treatments that

Drs. Henggeler and Linehan have developed for their respective

populations are truly remarkable. The editors believe that they will

2
provide invaluable insights into the treatment of the drug dependent

individual.

Methodological issues were highlighted at the technical review by

Drs. Borkovec, Moras, and Howard. In this monograph, Dr. Borkovec

explicates methodological and design guidelines for between-group

behavioral treatment research. One of the difficulties in doing good

behavioral drug dependence treatment research is obtaining valid and

reliable measurements of outcome. Dr. Moras has clearly described

strategies that may be used to maximize the ability to do this.

Dr. Howard, in his inimitable way, maintains that although clinical

researchers routinely design studies to determine main effects, they

typically end up rummaging through the data when main effects do not

appear looking for information (interactions) to explain the results.

Did the men respond to treatment and the women not? Did the people

who had spouses do well and the people without them poorly? In their

contribution to this monograph, Drs. Howard, Krause, and Lyons have

provided straightforward before-the-fact strategies to enable researchers

to disaggregate the data after the fact. The points that these fine

methodologists have made are well taken, and the editors of this

publication are confident that they will serve to enhance the quality of

behavioral drug dependence treatment research.

Dr. Schuster provided insights as to why behavioral treatments are not

more readily utilized outside of research settings. In their contribution

to the monograph, Drs. Schuster and Silverman have enumerated

concrete suggestions to facilitate the utilization of behavioral treatment

methods in drug dependence treatment settings. Dr. Miller, with a

combination of incisive thinking and humor, provided a commentary

on the points that were made at the meeting. As is strikingly apparent

in his second chapter and the final chapter to this monograph, he is

able to cut to the heart of problems, making the complicated and

muddled appear obvious and clear. The insights of Drs. Schuster and

Miller are greatly appreciated and, the editors are sure, will make

invaluable contributions to this field.

The editors of this monograph would like to extend our thanks to

Drs. Harry Haverkos and Robert Battjes, Director and Deputy Director

of the Division of Clinical Research, respectively, who made the

technical review that sparked this monograph possible. We also would

3
like to thank the fine group of technical review participants who

contributed to this monograph. Finally, we would like to inform the

field of NIDA’s dedication to supporting research in this area. NIDA

has launched a major initiative in this area, the Behavioral Therapies

Initiative, that affirms a continuing interest in expanding the support of

fine research on behavioral treatments for drug dependence.

REFERENCE

Hunt, G.M., and Azrin, N. A community reinforcement approach to

alcoholism. Behav Res Ther 11:91-104, 1973.

AUTHORS

Lisa Simon Onken, Ph.D.

Research Psychologist

Jack D. Blaine, M.D.

Chief

Clinical and Experimental Therapeutics Branch

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10AJohn J. Boren, Ph.D.

Chief

Behavioral Pharmacology Branch

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room l0A5600 Fishers Lane

Rockville, MD 20857

4
Advancing the Application of

Behavioral Treatment

Approaches for Drug

Dependence

Charles R. Schuster and Kenneth Silverman

Over the past 30 years, a range of behavioral interventions for drug

dependence have been found effective in diminishing drug use

(Childress et al. 1985; Stitzer et al. 1985, 1989); unfortunately, those

interventions have not been widely adopted by treatment providers.

The purpose of this chapter is to discuss methods that might facilitate

the widespread applications of behavioral treatment interventions that

have been shown to be efficacious in controlled studies. This topic,

which has been referred to as knowledge utilization, is not a problem

confined to the drug abuse treatment field but rather is an issue that is

common to all science-based applied activities, from engineering to

medicine. This is basically a problem of how behavioral change can

be best achieved, not in clients seeking treatment but rather in

treatment practitioners and in the researchers who are developing,

evaluating, and disseminating the new treatment approaches.

Why is this area of importance to both researchers and practitioners?

First, utilization of new behavioral interventions could result in

significant improvement in the success of prevention or treatment

practitioners. In addition, the public, the legislatures, and the insurance

companies that pay for treatment increasingly are demanding

accountability, asking, “Does it work? Are there more cost-effective

procedures?” It is also of importance to researchers, whose support

ultimately rests on the perception of society, and especially Congress,

that research does have some practical value. It is true that

fundamental research is of importance for knowledge generation in its

own right; humans are unique in their inquisitiveness about how the

world works, and societies should support scientists whose work

allows us all to vicariously express this need. However, it is also a

fact that society is increasingly demanding accountability, asking,

5
“What are we getting for our expenditures?” This means that scientists

must be increasingly cognizant of the relevance of their work to

applied fields.

IMPEDIMENTS TO THE APPLICATION OF RESEARCH

FINDINGS

What are some of the impediments to the application of behavioral

treatment research? First, this problem must be addressed with the

appropriate humility about what research can do for treatment

practitioners and with an appropriate respect for what they are

currently doing. It must be recognized that most frontline treatment

practitioners are not educated in the principles underlying behavioral

treatment approaches or in the jargon of treatment research. Further,

frontline treatment practitioners often deal with cases that would be

excluded from research studies. How many research studies reject

participation by those who are illiterate, have no fixed address, are

polydrug abusers, or have other psychiatric or other medical

complications? In addition, those in the trenches of the “drug war” are

underpaid, overworked, and often demoralized (Ball and Ross 1991;

Gustafson 1991). with little time or energy to read about the latest

treatment research findings in NIDA Notes, let alone apply them to

their own clinical activities. Furthermore, some of the frontline

treatment providers in drug abuse clinics are recovering addicts who

are emotionally tied to the approaches that they believe are responsible

for their successful rehabilitation. It is a small wonder, therefore, that

treatment practitioners are not using procedures that were described a

few months ago in a professional journal!

There are additional impediments to the acceptance of behavioral

procedures that are unique to this treatment approach. First, behavioral

approaches, if not fully explained and understood, sound mechanistic

and inhumane. To say, for example, the goal of treatment is to

“control the behavior of clients” sounds to most like an Orwellian state

with Big Brother watching. In addition, behavioral approaches are met

with skepticism by those who believe that addiction involves a

disordered brain that can only be reordered by a medication.

According to this view, behavioral interventions are inadequate because

they only affect symptoms and do not address the underlying causes of

6
drug abuse. Further, behavioral treatment programs may be expensive

to implement and require financial and staffing resources that are not

available to the average drug abuse treatment clinic. For example,

behavioral interventions often are evaluated in research clinics that

have client-to-staff ratios that are considerably greater than those in the

average clinic. Finally, behavioral approaches can be complex and

require a considerable amount of training to be properly applied.

Given these impediments, it is obvious that, if researchers are

interested in having new treatments applied, more must be done than

simply publishing data in professional journals or giving lectures at

professional conferences.

RESEARCH WITH THE GOAL OF WIDESPREAD

APPLICATION

Ideally, research progresses in a stepwise fashion from the laboratory,

in which basic principles are explored, to controlled studies, in which

those laboratory-derived principles are applied in the form of new

procedures to solve real problems, to widespread application under

real-world conditions, in which the empirically derived principles and

procedures are evaluated for their real-world utility. Behavioral

treatment interventions can readily follow this progression. Behavioral

approaches are firmly rooted in an extensive body of laboratory

research that has shown that drug self-administration in animals and

humans can be diminished by systematic manipulations of the

environment (Goldberg 1976; Griffiths et al. 1980; Johanson and

Schuster 1981; Pickens et al. 1978). The principles and procedures

that have proven effective in modulating drug-taking behavior in the

laboratory have served as the basis for the behavioral drug abuse

interventions that currently are being applied and evaluated in

controlled clinical research settings. This powerful tradition will no

doubt continue; behavioral researchers will continue to adapt

laboratory-derived principles and procedures to develop new and

effective behavioral treatments. At this point in the development of

behavioral approaches to drug abuse treatment, it is essential to focus

special attention on the final goal of widespread application. This

focus may help shape the development of new behavioral approaches

in ways that may facilitate their subsequent application.

7
In recent years, behavioral drug abuse treatments have been developed

and evaluated under relatively controlled circumstances in the context

of small-scale research programs funded largely by the National

Institute on Drug Abuse (NIDA). Many of these programs have

proven effective in reducing drug abuse (Childress et al. 1985; Stitzer

et al. 1985, 1989), and some programs have produced effects that have

not been equaled by other pharmacological or nonpharmacological

approaches (e.g., Higgins et al. 1991, in press). Although considerable

advances have been made by researchers developing and evaluating

behavioral interventions for drug abuse, this effort could benefit

considerably by a systematic and coordinated research program similar

to the NIDA Medications Development Program. A program of this

type could help focus the behavioral treatment research by developing

specific goals, including goals that might facilitate subsequent largescale application of behavioral treatments across the United States. In

fact, a NIDA Behavioral Therapies Development Program already has

been suggested by Dr. Snyder (personal communication), and NIDA

has formed a Workgroup to develop and implement the program.

The NIDA Behavioral Therapies Development Program could facilitate

the large-scale application of behavioral treatments by outlining a

number of specific objectives. First, it could encourage the

development of low-cost interventions that would use available

resources and that could be applied with minimal training of

counselors and other clinic staff professionals. Contingency

management programs in methadone maintenance clinics that provide

take-home methadone doses contingent on drug abstinence (as verified

by urinalysis) are good examples of low-cost, easily implemented

interventions of proven efficacy (Stitzer et al. 1984). These programs

are being refined and ultimately could be studied on a large-scale basis

in methadone clinics across the country to determine their general

utility.

Experience suggests that these low-cost programs will likely have

limitations. Contingency management programs, for example, have

been effective in reducing drug use as long as they are in effect, but

they have not had long-term effects. In addition, powerful reinforcers

like methadone may not be readily available to treatment providers

outside of methadone clinics, further limiting their general

applicability. Also, outside of research settings, the Federal methadone

8
regulations do not allow total flexibility for contingent take-home

methadone doses. Even if improved, these contingency management

programs probably will have to be considered as important elements in

comprehensive treatment programs designed to develop client

behaviors (lifestyles) that support drug abstinence and that are

incompatible with drug use. Those comprehensive programs are likely

to be costly and complex and to require extensive staff training to

implement. Research on this type of program is clearly necessary, and

the NIDA Behavioral Therapies Development Program could

encourage it. In addition, with a focus on eventual large-scale

application, the NIDA Behavioral Therapies Development Program

could encourage several other important activities. First, researchers

could be encouraged to create manuals and training procedures so that

the behavioral interventions could be taught to the staff in nonresearch

clinics. Second, studies analogous to labeling studies for

pharmacological treatments could be funded to examine whether the

behavioral interventions can be properly administered by staff in

nonresearch clinics, given the materials and training procedures

prescribed by the originators of the treatment. Third, efforts to

replicate the results of successful behavioral treatments could be

encouraged. Finally, researchers could be encouraged to conduct

economic analyses to determine if the treatments are cost-effective,

considering not only the actual costs of the treatment but also the

savings to society in terms of reductions in crime, the spread of human

immunodeficiency virus infection, etc. This type of analysis is

essential to be able to get funding sources to increase the amount of

money available for each treatment slot.

Effective drug abuse treatment interventions that can be packaged and

accurately and reliably taught to nonresearch treatment staff should be

evaluated in large-scale demonstration projects that involve a number

of nonresearch treatment clinics, preferably in more than one

geographical area. This research should evaluate process variables to

determine if the treatment approach is implemented adequately and

outcome variables to determine if the treatment is effective in reducing

drug abuse. The Center for Substance Abuse Treatment (CSAT), a

part of the Substance Abuse and Mental Health Services

Administration (SAMHSA), might fund such large-scale demonstration

projects and in this way support an important step in a focused effort

to disseminate new and effective behavioral treatments. By providing

9
special funding opportunities for research that is focused on ultimate

large-scale evaluation and application, the Behavioral Therapies

Development Program within NIDA, along with SAMHSA’s CSAT,

could facilitate the development of effective behavioral treatments for

drug abuse that have widespread applicability.

NIDA ENDORSEMENT OF EFFECTIVE AND EXPORTABLE

PROGRAMS

Interpretation of research is a time-consuming and complex matter.

Even if behavioral treatment approaches are thoroughly evaluated from

the laboratory to large-scale demonstration projects, it may be difficult

or impossible for frontline treatment providers to wade through all of

the relevant publications to identify the most suitable program for their

needs. To aid in the identification of effective and applicable

behavioral drug abuse treatment approaches, NIDA could establish an

independent committee or consensus group in which experts would

periodically review the current research and recommend treatment

approaches for adoption by the treatment community. This committee

could establish criteria and procedures for evaluating behavioral

treatment approaches similar to the criteria and procedures developed

by the Federal Drug Administration to evaluate new treatment

medications, but without the regulatory authority. Behavioral treatment

approaches that are recognized as effective and appropriate for largescale application could be announced to treatment providers in

marketing campaigns along with information about whom to contact

for aid in the implementation of the newly endorsed programs.

REINFORCEMENT CONTINGENCIES FOR PROVIDING

EFFECTIVE TREATMENT

A fundamental tenet of behavior analysis is that behavior is, to a large

degree, controlled by its consequences. This suggests that the problem

of application of research findings can be analyzed by identifying the

consequences of maintaining the behavior of researchers and

practitioners and employing these consequences to maximize the

effective utilization of research findings by practitioners. It is clear

that there are some natural reinforcers for the behavior of both

10
researchers and practitioners that support effective utilization of

research findings. There is no question that effectively preventing

drug abuse in the target population of adolescents or successfully

treating a drug-abusing client is highly rewarding to practitioners. In

postinterviews, attendees at a recent NIDA Technology Transfer

Conference expressed a need for training in the use of prevention and

treatment evaluation methods (Backer 1991). Similarly, researchers at

this conference who could see that the products of their work might be

successfully applied to prevention or treatment were gratified and

indicated their willingness to participate in future conferences where

practitioners and researchers could get together. However, as

discussed above, there are major impediments to the operation of these

natural reinforcement contingencies in shaping and maintaining the

behaviors of researchers and practitioners over the long term. It may

be necessary, therefore, to supplement these natural reinforcers with

systems that provide other reinforcers to maintain the behavior of

researchers and practitioners.

Some of the suggestions described above involve arranging

reinforcement contingencies for the behavior of researchers to develop

programs that are suitable for large-scale application. The funding

opportunities that will be offered by the NIDA Behavioral Therapies

Development Program for the development and evaluation of

behavioral treatment programs that are designed and suitable for largescale application may help shape and maintain research activities that

are focused on large-scale application. The opportunity to conduct

large-scale demonstration projects with funding by SAMHSA’s CSAT

might have two effects. First, it might encourage NIDA-funded

researchers to develop programs that appear suitable for widespread

application so that those programs could be evaluated in large-scale

demonstration projects funded by CSAT. Second, the funding

opportunities to conduct large-scale demonstration projects should

generate a substantial amount of behavior. Finally, recognition of the

efficacy and general utility of a particular treatment approach by a

NIDA body of experts also might function as a reinforcer for the

researchers who designed and evaluated the recognized treatment

approach, particularly if that recognition is useful to those researchers

in obtaining future NIDA grants and grants from CSAT.

11
One of two types of reinforcement contingencies could be arranged for

the behavior of treatment practitioners. First, reinforcement

contingencies could be arranged for adopting and utilizing treatment

approaches that have been proven effective through research.

Although this approach may have some appeal, it is probably

impractical. Treatment approaches can be implemented with varying

degrees of skill and accuracy. The same treatment approach can be

implemented by one clinic or one counselor properly and with great

effectiveness while another clinic or counselor may implement the

approach poorly, retaining its basic fonn while loosing much of its

function. Determining whether or not a clinic or a counselor is

properly implementing the treatment approach so that the reinforcers

can be applied would be very difficult in many situations.

Alternatively, reinforcement contingencies could be arranged for

providing effective drug abuse treatment. Reinforcement contingencies

of this type should function to increase the effectiveness of the

treatment provided; in addition, those reinforcement contingencies

might increase the likelihood that treatment programs and treatment

practitioners would seek out and adopt new interventions that have

been determined to be effective through research. Unlike many types

of treatment, the effectiveness of drug abuse treatment can be

objectively and reliably determined through regular urinalysis. Using

urine results, reinforcement contingencies could be arranged at the

level of the treatment program as well as at the level of the individual

treatment provider. Currently, State and Federal funds to treatment

programs are provided for those programs for complying with

structural requirements. To increase treatment effectiveness and to

increase the likelihood that treatment programs would adopt new and

effective behavioral treatments, States and the Federal Government

could make funding decisions based on the demonstrated effectiveness

of treatment programs. This could be accomplished by providing more

funds to programs that are effective relative to other ongoing programs

in retaining patients in treatment, reducing drug use, and producing

long-term effects. Similar contingencies could be arranged for the

individual treatment providers. Counselors, for example, could receive

benefits for retaining their patients in treatment, reducing drug use, and

producing long-term effects in their patients (cf., McCaul and Svikis

1991). The effectiveness of these contingencies should increase as a

function of the magnitude of the reinforcement contingencies,

12
suggesting that substantial monetary consequences will be most

effective; however, given existing funding limitations, it may be

necessary to provide consequences that are probably weaker but

available to treatment programs such as flexible working hours,

decreased caseloads, parking spaces, reduced paperwork requirements,

and opportunities to attend conferences.

Reinforcement contingencies cannot be arranged for effective treatment

unless adequate systems are in place to evaluate treatment

effectiveness. Such systems necessarily will include regular urinalysis

testing and regular monitoring of that testing by an independent agent.

No doubt, contingencies on effectiveness would have a number of

effects, some of which may be undesirable (e.g., accepting into

treatment only patients who are likely to succeed). Therefore, the

precise delineation of the guidelines and controls for implementing

reinforcement contingencies for treatment effectiveness will require

careful planning. Furthermore, although the recommendations to

reinforce effective treatment by treatment programs and by individual

treatment providers are reasonable and are based on an extensive body

of literature on the effects of similar reinforcement contingencies on

human behavior in other treatment situations (e.g., Iwata et al. 1976;

Greene et al. 1978), reinforcement contingencies of this type have not

been studied in the administration of drug abuse treatment and would

be important subjects of future research.

TRAINING TREATMENT PRACTITIONERS

The majority of practitioners in the drug abuse field today are not

skilled in behavioral treatment approaches, and some practitioners are

philosophically opposed to such interventions, or at least are skilled in

approaches that are antithetical to behavioral approaches. It seems

reasonable that new behavioral treatments will be most appealing and

most easily taught to practitioners with prior training in behavioral

approaches. Therefore, efforts must be made to increase the number of

counselors, psychologists, and psychiatrists receiving training in

behavioral approaches. Currently, CSAT (through the Substance

Abuse Counselor Training Program) provides training in drug abuse

counseling to people entering the drug abuse treatment field.

Advances in the application of effective behavioral treatments could be

13
made if NIDA researchers who develop new and effective behavioral

treatment interventions were encouraged to contribute to this training

program. Increasing the number of college and university programs

for counselors, psychologists, and psychiatrists that provide training in

behavioral approaches would further prepare the treatment community

to accept and effectively utilize new behavioral interventions.

CONCLUSION

Five steps have been proposed to facilitate the widespread application

of behavioral drug abuse treatment approaches: (1) the funding by

NIDA’s Behavioral Therapies Development Program of research

efforts designed to facilitate widespread application of behavioral

treatments, (2) the funding of large-scale demonstration projects by

SAMHSA’s CSAT to evaluate the widespread applicability of

behavioral treatment approaches that have been found effective and

reproducible in the smaller and more controlled NIDA-funded projects,

(3) the creation by NIDA of a committee or consensus conference of

experts that periodically would review behavioral treatment research

and endorse and market to treatment providers the approaches

recognized as effective, (4) the administration of State and Federal

funds to treatment programs contingent on providing effective

treatment relative to similar treatment programs and the arrangement of

reinforcement contingencies for individual treatment practitioners for

providing effective treatment, and (5) an increased focus on providing

training in behavioral approaches to drug abuse counselors in CSAT’s

Substance Abuse Counselor Training Program as well as to counselors,

psychologists, and psychiatrists in college and university programs.

The success of efforts to apply behavioral treatments will also depend

on the reaction and cooperation of the communities in which the drug

abusers live. Clearly, behavioral treatments, which often focus on the

development of behaviors that compete with drug abuse, will be most

likely to succeed in communities that support those efforts, for

example, by providing jobs and recreational opportunities to people in

drug abuse treatment. Although some of this community involvement

can be recruited by treatment practitioners, community support also

14
can be encouraged through public education campaigns that prepare

communities to accept the view that drug abuse can be treated by

strategically molding and enriching the environments of drug abusers.

REFERENCES

Backer, T.E. “Evaluations of the 1991 National Conference on Drug

Abuse Research and Practice.” Report prepared for National

Institute on Drug Abuse, 1991.

Ball, J.C., and Ross, A. The Effectiveness of Methadone Maintenance

Treatment. New York: Springer-Verlag, 1991.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Behavioral

therapies for substance abuse, Int J Addict 20:947-969, 1985.

Goldberg, S.R. The behavioral analysis of drug addiction. In: Glick,

S.D., and Goldfarb, J., eds. Behavioral Pharmacology. St. Louis:

C.V. Mosby Company, 1976. pp. 283-316.

Greene, B.F.; Willis, B.S.; Levy, R.; and Bailey, J.S. Measuring client

gains from staff implemented programs. J Appl Behav Anal

11:395-412, 1978.

Griffiths, R.R.; Bigelow, G.E.; and Henningfield, J.E. Similarities in

animal and human drug-taking behavior. In: Mello, N.K., ed.

Advances in Substance Abuse: Behavioral and Biological Research.

Vol 1. Greenwich, CT: JAI Press, 1980. pp. 1-90.

Gustafson, J.S. Do more . . . and do it better: Staff-related issues in the

drug treatment field that affect the quality and effectiveness of

services. In: Pickens, R.W.; Leukefeld, C.G.; and Schuster, C.R.,

eds. Improving Drug Abuse Treatment. National Institute on Drug

Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991.

pp. 53-62.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.;

and Badger, G. Achieving cocaine abstinence with a behavioral

approach. Am J Psychiatry, in press.

Higgins, S.T.; Delaney, D.D.; Budney, A.J.; Bickel, W.K.; Hughes,

J.R.; Foerg, F.; and Fenwick, J.W. A behavioral approach to

achieving initial cocaine abstinence. Am J Psychiatry

148:1218-1224, 1991.

15
Iwata, B.A.; Bailey, J.S.; Brown, K.M.; Foshee, T.J.; and Alpern, M. A

performance-based lottery to improve residential care and training

by institutional staff. J Appl Behav Anal 9:417-431, 1976.

Johanson, C.E., and Schuster, C.R. Animal models of drug

self-administration. In: Mello, N.K., ed. Advances in Substance

Abuse: Behavioral and Biological Research. Vol. II. Greenwich,

CT: JAI Press, 1981. pp. 219-297.

McCaul, M.E., and Svikis, D.S. Improving client compliance in

outpatient treatment: Counselor-targeted interventions. In: Pickens,

R.W.; Leukefeld, C.G.; and Schuster, C.R., eds. Improving Drug

Abuse Treatment. National Institute on Drug Abuse Research

Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 204-217.

Pickens, R.W.; Meisch, R.; and Thompson, T. Drug selfadministration: An analysis of the reinforcing effects of drugs. In:

Iversen, L.L.; Iverson, S.D.; and Snyder, S.H., eds. Handbook of

Psychopharmacology. Vol. 12. New York: Plenum, 1978. pp. 1-37.

Stitzer, M.L.; Bigelow, G.E.; and Gross, J. Behavioral treatments of

drug abuse. In: Karasu, T.B., ed. Treatments of Psychiatric

Disorders: A Task Force Report of the American Psychiatric

Association. Vol 2. Washington, DC: American Psychiatric

Association, 1989. pp. 1430-1448.

Stitzer, M.L.; Bigelow, G.E.; Liebson, I.A.; and McCaul, M.E.

Contingency management of supplemental drug use during

methadone maintenance. In: Grabowski, J.; Stitzer, M.L.; and

Henningfield, J.E., eds. Behavioral Intervention Techniques in Drug

Abuse Treatment. National Institute on Drug Abuse Research

Monograph 46. DHHS Pub. No (ADM)84-1282. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 84-103.

Stitzer, M.L.; Bigelow, G.E.; and McCaul, M.E. Behavior therapy and

drug abuse treatment: Review and evaluation. In: Ashery, R.S., ed.

Progress in the Development of Cost-Effective Treatment for Drug

Abusers. National Institute on Drug Abuse Research Monograph 58.

DHHS Pub. No. (ADM)88-1401. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1985. pp. 31-50.

16
AUTHORS

Charles R. Schuster, Ph.D.

Senior Scientist

Kenneth Silverman, Ph.D.

Staff Fellow

Addiction Research Center

National Institute on Drug Abuse

4940 Eastern Avenue

Baltimore, MD 21224

17

Contingency Management in

Methadone Treatment: The Case

for Positive Incentives

Maxine L. Stitzer, Martin Y. Iguchi, Michael Kidorf, and

George E. Bigelow

INTRODUCTION

Methadone maintenance has been widely and effectively implemented

for nearly 30 years as a treatment for opiate dependence. During

methadone treatment, heroin use is suppressed through

pharmacological satiation and cross-tolerance. However, methadone

does not directly address the full array of substance abuse problems

that patients often bring to the treatment setting. In particular, the

continued use and abuse of drugs from nonopiate pharmacological

classes is recognized as a significant clinical problem in contemporary

methadone programs. Cocaine use is widespread among methadone

patients (Kosten et al. 1986; Hanbury et al. 1986; Condelli et al. 1991),

and benzodiazepine tranquilizers also still are abused by a subset of

patients (Stitzer et al. 1982; Iguchi et al., in press). Aversive

contingencies involving treatment termination are readily available and

widely employed by counseling staff in an effort to promote behavior

change among their patients, including cessation of supplemental drug

use. Typically, a contract is negotiated with the patient in which

parameters of improved performance are specified that must be

achieved within a delineated timeframe, with the consequence of

nonperformance being gradual dose-tapering and ultimately treatment

termination. Previous studies have indicated that clearly specified

aversive contingencies involving the threat of dose reduction or

treatment termination can be effective for promoting improved

treatment outcomes (Dolan et al. 1985; McCarthy and Borders 1985;

Stitzer et al. 1986). However, the disadvantage of this approach is that

poorly performing patients, who are often the neediest and most

severely drug-dependent individuals, are likely to be terminated from

treatment (Iguchi et al. 1988; Stitzer et al. 1986).

19
Positive incentives also are available in the context of methadone clinic

operation that can be used to influence abuse of nonopiate drugs

during methadone treatment. Specifically, clients can be offered

tangible rewards or incentives contingent upon objective urinalysis

evidence that they have complied with program requirements or have

recently abstained from the supplemental drugs typically used.

Previous studies have shown that the methadone medication take-home

privilege, whereby clients can miss a day of clinic reporting and ingest

their daily medication dose at home, is desirable to clients (Stitzer and

Bigelow 1978) and effective as an incentive for use in contingency

management programs. An early study by Stitzer and colleagues

(1982) and a more recent study by Iguchi and colleagues (1988) both

offered medication take-home privileges based on drug-free urines and

demonstrated that 40 to 50 percent of the benzodiazepine-abusing

methadone patients enrolled as subjects reduced or eliminated their

supplemental benzodiazepine use during intervention trials lasting from

12 to 20 weeks. Magura and colleagues (1988) found that l-month

contracting for contingent take-homes produced a favorable response

(i.e., drug abstinence) in 34 percent of their polydrug-abusing subjects,

while Milby and colleagues (1978) found a similar percentage of

clients responding to a take-home incentive program with increased

numbers of consecutive drug-free urines, as required by the

intervention.

Most of these early studies focused on selected groups of identified

polydrug-abusers and used within-subjects designs to evaluate

effectiveness of contingent take-home programs. A more recent study,

which will be described below, used a controlled clinical trials design

to evaluate the extent to which contingent take-home privileges would

influence drug abuse outcomes of an unselected group of new intakes

to methadone maintenance treatment (Stitzer et al. 1992). It should be

noted that these studies of methadone take-home privileges have

particular clinical relevance because they emphasize the use of

take-home privileges in a flexible and responsive manner to motivate

periods of abstinence from drug use in polydmg-abusing patients. This

is in contrast to the way that take-home privileges often are used as

awards only to patients with long-standing histories of abstinence from

all illicit drugs.

20
CONTINGENT TAKE-HOME STUDY: METHODS

Subjects

Study participants in the recently conducted clinical trials study were

53 patients newly admitted to methadone maintenance treatment.

Demographic profile was typical for a lower income methadone

maintenance population: average age was 34 years (±6.7 yrs),

72 percent were male, 66 percent were white (the remainder being

black), 34 percent were employed, and 23 percent were married at

treatment entry. Forty percent had no current involvement with the

criminal justice system, the remainder were either on probation (38

percent) or free pending trial (22 percent). There were no statistically

significant differences between the study groups on any of the

demographic variables.

Baseline Drug Use

Drug use was detected in 64 percent of urines collected during the first

3 months following treatment enrollment, which constituted the

baseline evaluation phase. This high overall rate of drug-positive urine

samples probably reflects both a sampling bias in patients admitted to

treatment, since the authors’ clinic has a reputation for accepting

polydrug abusers, and also may be due to the very intensive urinalysis

testing schedule employed that was designed to maximize detection of

drug use. Cocaine and benzodiazepines were detected in urine testing

with approximately equal frequency (cocaine in 32 percent of samples

positive, and benzodiazepines in 38 percent). There were no

significant differences between the groups in rates or patterns of

baseline drug use. Individual subjects usually displayed clear biases in

selecting their supplemental drugs. Of the 53 subjects included in the

data analysis, urine testing indicated that 22 (41.5 percent) primarily

used benzodiazepines alone or benzodiazepines and opiates, while

another 20 (37.7 percent) primarily used cocaine alone or cocaine and

opiates, and 3 primarily used opiates alone. Four had both cocaine and

benzodiazepines in more than 50 percent of their urines, and four

could not be assigned a primary drug of abuse due to low frequency of

detection of any drug.

21
Clinic Procedures

During the study, subjects reported to the clinic every day to ingest

their methadone dose in a cherry syrup vehicle under nursing

supervision (unless they previously had been assigned to receive a

take-home dose of methadone for that day). Average methadone dose

was 51.4 mg/day (range = 30 to 60 mg; mode = 50). Subjects also

were expected to participate in weekly drug abuse counseling and an

intensive urine monitoring schedule. Urines collected during the study

were tested for opiates, cocaine, and benzodiazepines using a sensitive

and selective immunoassay procedure (Enzyme Multiplied

Immunoassay Test [EMIT]) and tested using thin-layer chromatography

(TLC) for the broad array of sedative and stimulant drugs that can be

detected with this procedure. Contingencies in this study were based

on all drugs that could be detected by either of these methods.

Study Condition Assignment

Subjects were stabilized for 12 weeks following treatment admission;

this served as baseline for the random assignment study. At this point,

subjects were stratified on gender and race and randomly assigned to

one of two conditions: contingent (n = 26) or noncontingent (n = 27)

opportunity to receive methadone take-homes. Subjects continued on

the assigned protocol for 6 months, at which time the noncontingent

study subjects still in treatment (n = 18) were switched to the

contingent protocol.

Take-Home Procedures

Subjects in the noncontingent condition were assigned randomly at the

beginning of each calendar month to receive zero, one, two, or three

take-home doses of methadone per week for the month. These

take-home doses were delivered independent of urine test results.

Under the contingent protocol, subjects could earn a maximum of three

take-home doses per week (Tuesday, Thursday, and Saturday). The

first (Tuesday) take-home privilege was assigned after six consecutive

drug-free urines (2 weeks) had been observed. An additional

take-home day (Thursday, then Saturday) was authorized following

each additional successive 2-week drug-free period. Thus, six

22
consecutive drug-free weeks (18 consecutive urines) were required to

earn the maximum number of take-homes. One take-home dose was

forfeited for each drug-positive urine sample detected either by EMIT

or by TLC analysis within a given 2-week block. Following a

reduction or cancellation of take-home privileges, 2 full weeks of

drug-free urinalysis results were required to earn back each take-home

day. The rationale for the 2-week requirement of drug-free urines was

that this represents a clinically meaningful period of drug abstinence

that at the same time can be an achievable goal for the population of

chronic supplemental users of cocaine or benzodiazepines.

CONTINGENT TAKE-HOME STUDY: RESULTS

Retention

Mean retention duration during the intervention period was 23 weeks,

with no difference between the groups. Overall, about 30 percent of

originally assigned subjects dropped out of treatment before the end of

the 6-month evaluation. Early dropouts exhibited more polydrug abuse

during baseline than did those who stayed in treatment.

Urine Testing Outcomes: Conditional Probabilities

of Change

In order to give equal weight to urine results of early dropouts and

those retained throughout the evaluation, data analysis was based on

the overall percentage of positive urine samples given by each subject

during baseline and during the portion of the intervention evaluation in

which he or she participated. In this way, data from each subject

contributed equally to the analysis whether or not the subject stayed

through the entire intervention period. The primary focus of data

analysis was an examination of the conditional probabilities of change

(i.e., the probability that patients who could improve would improve

and patients who could worsen would worsen during intervention as

compared to baseline). Subjects who could improve were defined as

those whose baseline rate of drug-free urines was 90 percent or less;

these patients (n = 25 contingent, 25 noncontingent) were classified as

improving if their rate of drug-free urines increased by 10 percent or

more during the intervention. Subjects who could worsen were

23
defined as those whose baseline drug-free urine rate was 10 percent or

more; these patients (n = 20 contingent, 21 noncontingent) were

classified as worsening if their rate of drug-free urines decreased by

10 percent or more during the intervention. The ±10 percent criterion

for defining change was selected to eliminate from consideration small

changes in urine test results based on chance fluctuations.

As shown in figure 1, 32 percent (8 of 25) of contingent subjects who

could improve did improve their drug-free urine test rate by 10 percent

or more. In the noncontingent group, only 12 percent (3 of 25) who

could improve did improve. Thus, the chances of improving were

2.5-fold greater for contingent than for noncontingent subjects. In the

contingent group, 35 percent (7 of 20) of contingent subjects who

could worsen showed a decline of 10 percent or greater in percentage

of drug-free urines. In the noncontingent group, 62 percent (13 of 21)

who could worsen did worsen. Thus, there was twice the chance of

worsening in the noncontingent as compared with the contingent

condition.

Clinical Improvement Criteria

In order to apply a more stringent definition of clinical improvement,

subjects were required to improve their drug-free urine test rate by

10 percent or more and to have in addition at least 4 consecutive

weeks (12 consecutive samples) of drug-free urines during the

intervention period. The requirement for 4 consecutive weeks of

abstinence is consistent with criteria recently utilized by the Food and

Drug Administration (FDA) in evaluating the efficacy of medications

used as cessation aids in tobacco dependence treatment. All the

subjects in the contingent group who improved their urine test results

also met the 4-week abstinence criterion, but one subject in the

noncontingent group failed to meet the additional criterion. The

groups differed significantly on percentage of patients meeting this

criterion of improvement (32 percent versus 8 percent; z = 2.12,

p<.05).

Magnitude of Change

Subjects in the contingent group who improved during the study

submitted on average 42 percent drug-free urines during baseline and

24
FIGURE 1. The percentage of subjects who improved urine test

results by 10 percent or more from baseline to

intervention periods is shown in the upper panel for

contingent (n=25) and noncontingent (n=25) subjects who

could improve. The percentage of subjects whose urine

test results worsened from baseline to intervention periods

is shown in the lower panel for the contingent (n=20) and

noncontingent (n=21) subjects who could worsen.

25
70 percent drug-free urines during the intervention. Thus, while the

criteria required a 10-percent improvement, these subjects were

actually improving their urine drug-free test rate by nearly 30 percent

on average. Further, these patients remained continuously abstinent for

9.4 weeks on average, although the criteria required only 4 weeks

(range = 5.3-15.3 weeks) during the intervention. A final point to be

made about treatment outcome is that subjects who improved were

equally likely to be cocaine or benzodiazepine abusers. This fails to

support a previous suggestion that cocaine abuse may be harder to treat

than other forms of drug abuse (Magma et al. 1988).

Replication In Noncontingent Patients

The noncontingent patients (n = 18) who switched to the contingent

protocol later in treatment were evaluated using the same improvement

criteria described above for the contingent group in the main study.

Of those who were able to improve (n = 16), 28 percent met the

stringent criteria of clinical improvement, including at least 4 weeks of

continuous abstinence during the evaluation period. Thus, this partial

crossover feature of the study provided a within-subject replication of

the main study findings.

Prediction of Positive Treatment Response

A strong predictor of positive response was baseline rate of drug-free

urines, as illustrated in figure 2. All contingent subjects who improved

their rate of drug use and earned take-homes during the treatment

intervention had a 33-percent or better drug-free urine rate during

baseline. In other words, these patients had submitted on average one

or more drug-free urine samples per week under the 3-times-per-week

testing schedule, suggesting a sporadic rather than continuous pattern

of supplemental drug use. In contrast, there were no treatment

responders among the subset of contingent intervention patients

(n = 10) who submitted a very high proportion of drug-positive urines

during baseline. The same relationship between baseline urine test

results and subsequent treatment response was noted for the

noncontingent patients who switched to the contingent protocol later in

their treatment (right panel). Further, a similar relationship was noted

with regard to multiple drug use (data not shown); treatment

26
Baseline Urinalysis Results Predict Treatment Response

Contingent Group Noncontingent Group

FlGURE 2. Characteristics of baseline drug use are shown for individual study participants who were able to

improve their urine test results. Subjects from the original contingent group (n=25) are shown in

the left panel while those from the delayed-exposure partial crossover group (n=16) are shown in

the right panel. Data for each subject are the percent of baseline urines testing positive for any

illicit drug. Filled bars represent individual subjects who met the criteria for clinical

improvement during the intervention (10 percent or greater improvement in percentage of

drug-free urine tests and submission of at least 12 consecutive drug-free urine samples).
responders tended to submit relatively few urines containing more than

one drug of abuse, while treatment failures were more likely to show

evidence of polydrug supplementation.

Study Summary

Thus, the controlled random assignment study showed that a subset of

new treatment intakes responded favorably to a contingent take-home

intervention that offered a desirable and practical clinic privilege

(take-home medication) as an immediate incentive for objective

evidence of supplemental drug abstinence. In contrast, the most likely

outcome for subjects given noncontingent access to the take-home

privilege was a worsening of treatment outcome vis-a-vis supplemental

drug use. The 30-percent treatment response rate was replicated when

noncontingent subjects were switched to the contingent protocol in a

partial crossover. Further, no adverse effects of the take-home

privilege were detected in terms of treatment retention or patterns of

cessation and relapse. Finally, positive therapeutic response to the

contingent take-home intervention was associated with lower rates of

drug-positive urines submitted during baseline.

CONTINGENT TAKE-HOMES AS ROUTINE CARE

Subsequent to completion of the contingent take-home study, the

methadone maintenance research clinic where the study had been

conducted adopted the policy of offering take-home privileges to all

entering clients based on drug-free urine test results. Initially,

following FDA guidelines, patients had to wait 3 months after

enrolling in treatment before take-home privileges could be earned.

Following approval of an FDA exemption from the 90-day

requirement, take-homes were offered after 1 month of treatment

enrollment. The protocol for take-home earning and loss was identical

to that described for the controlled study, following the 2-week rule.

Among patients entering treatment during a 1-year period (n = 84), it

was observed that 24 percent achieved the maximum number of takehome days (i.e., 3 days per week) during their first year of eligibility

for take-home privileges, indicating that they had achieved at least 6

weeks of continuous abstinence from supplemental drugs. The mean

number of take-homes earned was 57 (range = 11-144), with the

28
minimum number of take-homes representing about 8 drug-free weeks.

The success rate observed in this clinical treatment sample closely

paralleled the success rate seen during the controlled study and adds

further credence to the effectiveness of the incentive program for

motivating drug abstinence among methadone maintenance patients.

Predictors of positive treatment response for the clinic sample included

lower baseline rates of drug-free urines, as previously seen in the

controlled study. However, take-home earners in the clinic treatment

sample were also much more likely to be employed and much less

likely to have a drug-abusing sexual partner than patients who failed to

earn take-homes during treatment. Thus, additional prognostic

variables were identified in this sample.

GENERAL DISCUSSION

Research fmdings suggest that several structured incentive protocols

are effective in promoting improved treatment outcomes among

polydrug-supplementing methadone maintenance patients. To date, the

incentives examined have been those that are implemented readily

within the context of a treatment program that dispenses daily

methadone. The interventions include contingent take-home incentives

(Magura et al. 1988; Stitzer et al. 1992), contingent dose-change

incentives (Stitzer et al. 1986), and treatment termination contracting

(Dolan et al. 1985). In general, these structured incentive approaches

have promoted improved outcomes in the range of 25 to 50 percent of

patients. There is no evidence to suggest that one type of incentive

program or combination of incentives is more effective than another.

The foregoing observations suggest that incentive programs appear to

be a good place to start for making inroads into the chronic

supplemental drug use of methadone patients. Take-home incentive,

altered-dose incentive, and treatment termination contracting protocols

are implemented easily within the context of a drug abuse treatment

clinic that dispenses methadone. All contingent incentive strategies

provide structure and clearly defined expectations for the patient

treatment plan and can be effective with a subset of patients. How can

clinics choose among these specific intervention strategies?

29
The positive findings from the random assignment study as well as

medical and ethical concerns support a recommendation that contingent

take-home incentives be used as the primary routine care intervention

in methadone clinics to promote improved treatment outcomes for

polydrug-abusing patients. The program is consistent with known

principles of effective behavioral management. By offering a reward

for the beginning steps of change (i.e., 2 weeks of drug-free urines),

the program defines a reachable short-term goal that can provide the

basis for longer term improvement. The use of positive incentives that

give patients something to gain but nothing to lose can provide a

refreshing change from the coercive tactics often employed in drug

treatment programs. Positive incentives also eliminate the ethical

dilemma of forced early treatment termination for the more highly

drug-dependent and impaired patients. Although contingent dose

increases may have a role in treatment, interventions that involve

contingent methadone dose reductions violate the medical precepts of

treatment because an adequate and stable methadone dose is imperative

for successful methadone maintenance. Further, since patients assigned

to interventions involving dose reduction tend to drop out of treatment

(Stitzer et al. 1986; Iguchi et al. 1988), the impact of withdrawing

treatment needs to be considered if such interventions are employed as

disciplinary actions. To this end, it would be useful to define more

clearly the characteristics of patients who perform poorly in standard

methadone treatment and to determine for this group the specific

health, longevity, drug use, and psychosocial benefits associated with

continuing long-term treatment involvement versus return to the

community through treatment dropout or disciplinary termination.

Contingent incentive programs have received a considerable amount of

attention in controlled research, perhaps because these are readily

available and convenient to implement in routine clinical care. Thus,

for example, the controlled study described in this chapter

demonstrated that the methadone take-home privilege awarded after

2 consecutive weeks of drug-free urines was effective in promoting

abstinence from cocaine and benzodiazepines used during methadone

maintenance treatment. The probability of improvement in drug use

outcome was 2.5-fold greater for patients who received their takehomes contingent on urine test results than for patients who received

take-homes independent of urine test results, while the probability of

worsening on the objective drug use measure was twice as great for

30
noncontingent than for contingent treatment patients. Further,

32 percent of contingent patients achieved sustained periods of

abstinence from supplemental drugs. The conclusion of clinical

effectiveness for the take-home incentive protocol was supported

further when research findings were translated into routine clinical

practice, where it was observed that 24 percent of new treatment

intakes successfully earned take-homes when the contingent procedure

subsequently was implemented as routine care. These data also are

consistent with global impressions of clinical staff that patients

enrolled in the contingent take-home intervention were trying to

discontinue illicit drug use, while patients in the noncontingent

condition tended to be “out of control” with respect to drug use.

Previous studies have shown that collection of urine test data has little

benefit in and of itself unless the data are put to some use (Goldstein

et al. 1977; Havassy and Hall 1981; Milby et al. 1980). The research

on contingent take-homes provides the basis for a rational use of urine

test results to shape behavior and promote improved clinical outcomes

for methadone patients. Practicality of the intervention may rest in

part on the ability of programs to implement frequent urine testing

programs. With short-acting drugs like cocaine as the target of

intervention, urine testing two or three times per week would be

advantageous, while randomized testing once weekly would appear to

be a minimum requirement. One strategy that might be considered for

efficient use of urine testing resources would be to test intensively

those patients who are attempting to achieve drug abstinence and earn

incentives while placing other patients on a minimal testing regimen.

This strategy reflects the rationale that urine testing is much more

useful for confirming drug abstinence than for confirming ongoing

drug use.

To put the research findings into proper perspective, it must be

acknowledged that in fact the majority of methadone maintenance

patients have not responded to contingent incentive interventions with

therapeutic improvement. Thus, it appears that treatment modifications

are needed to impact on a larger proportion of patients. One possible

avenue is to require less behavior change so that more patients can

experience success and receive the incentives being offered (i.e., a

“shaping” strategy). Thus, for example, take-homes could be offered

for a single drug-free urine or even for evidence of reduced use

31
obtained through quantitative urine testing methods. A second avenue

would be to develop more potent incentives. The incentives available

at the clinic, including take-home doses, could be supplemented with

material incentives (i.e., goods and services) available in the

community, using as a model the “voucher” system recently described

by Higgins and colleagues (1993) for the treatment of primary cocaine

abusers. This approach has the advantage of providing more

individualized incentives, since patients earn vouchers with a cash

value for improved performance but can select their own specific

rewards in exchange for the vouchers.

Another possible avenue to developing more potent incentives might

lie in combining the positive incentive approach with a structured

aversive contingency involving treatment termination. This would be

worth evaluating, since the threat of treatment termination is employed

so widely in methadone clinics and since both positive and aversive

interventions have some demonstrated efficacy. Thus, it might be

possible to achieve additive effects through their combined use,

particularly if different patient subgroups responded to negative versus

positive incentive approaches. However, two previous small-sample

studies from this laboratory have suggested that the combined approach

would not be particularly fruitful. Stitzer and colleagues (1986)

compared drug abuse treatment outcomes for patients (n = 10) who

could receive gradual methadone dose raises (up to 30 mg higher than

their 50 mg baseline dose) if they provided drug-free urines versus

outcomes for patients (n = 10) who received gradual dose reductions

(down to 30 mg below their 50 mg baseline dose) as a consequence of

providing drug-positive urines. Interestingly, the same percentage of

patients in each group (50 percent) responded by providing drug-free

urines during the 18-week trial. A more direct test of the combined

treatment idea was provided by Iguchi and colleagues (1988). In this

experiment, all study patients could earn take-homes by submitting

drug-free urines, while half the patients (n = 8) received an additional

dose-reduction contingency leading eventually to a 0 mg methadone

dose if they continued to provide drug-positive urines. Surprisingly,

the percentage of patients responding with drug-free urines during the

intervention was the same for the two treatment groups (38 percent),

suggesting that the two interventions did not produce an additive effect

on patient response. It is nevertheless plausible that different patients

would respond to programs offering different specific incentives, and

32
additional research characterizing treatment responders versus

nonresponders as a function of the type of contingent incentive

program implemented would be useful.

It is important in general to identify patient characteristics associated

with good versus poor treatment response in order to select appropriate

available treatments, to more effectively channel treatment resources,

and to develop rational treatment interventions for patient subgroups.

Baseline rate of drug-free urines has been identified as an important

predictor of treatment response, with lighter users who occasionally

submit drug-free urines being more likely to succeed in a take-home

incentive program (Stitzer et al. 1992) or a treatment termination

contracting program (Dolan et al. 1986) compared with heavier users

who rarely submit a drug-free urine. Social stability, including

employment and living with a partner who does not abuse drugs, was

also an important predictor in the clinical sample exposed to take-home

incentives. Interestingly, within the contingent treatment group of the

random assignment study, there were additional patients who had a

good outcome prognosis based on urine profile (i.e., they submitted

20 to 60 percent drug-positive urines during baseline; figure 2) but

who did not respond to the take-home intervention by further reducing

their drug use. One strategy for effective use of counseling resources

would be to target these better prognosis individuals for additional

intensive therapy in order to discover and eliminate barriers to

abstinence. Intensified counseling for better as opposed to poorer

prognosis patients might be a more efficient use of therapeutic

resources, since at present there is little information about what

strategies are effective with the poorest prognosis patients.

Research findings support the recommendation that structured incentive

protocols, particularly those involving contingent take-home privileges,

can and should be incorporated, along with adequate supportive

counseling, for the routine treatment of methadone maintenance

patients who supplement with cocaine or benzodiazepines during

treatment. A positive response, with improved outcome on drug use

measures, can be expected in one-quarter to one-half of these patients.

The task that remains for researchers and clinicians is to design more

potent interventions that can impact the ongoing supplemental drug use

of patients who fail to respond to available positive incentive programs

such as contingent take-homes. These interventions most likely will

33
involve offering more potent incentives for evidence of recent

abstinence, employing principles of shaping to encourage small

changes leading to drug abstinence, and addressing lifestyle factors and

skills deficits that may act as impediments to abstinence.

REFERENCES

Condelli, W.S.; Fairbank, J.A.; Dennis, M.L.; and Rachal, J.V. Cocaine

use by clients in methadone programs: Significance, scope, and

behavioral interventions. J Subst Abuse Treat 8:203-212, 1991.

Dolan, M.P.; Black, J.L.; Penk, W.E.; Rabinowitz, R.; and DeFord,

H.A. Contracting for treatment termination to reduce illicit drug use

among methadone maintenance treatment failures. J Consult Clin

Psychol 53:549-551, 1985.

Dolan, M.P.; Black, J.L.; Penk, W.E.; Rabinowitz, R.; and DeFord,

H.A. Predicting the outcome of contingency contracting for drug

abuse. Behav Ther 17:470-474, 1986.

Goldstein, A.; Horns, W.H.; and Hansteen, R.W. Is on-site urine

testing of therapeutic value in a methadone treatment program? Int J

Addict 12:717-728, 1977.

Hanbury, R.; Sturiano, V.; Cohen, M.; Stimmel, B.; and Aguillaume,

C. Cocaine use in persons on methadone maintenance. Adv Alcohol

Subst Abuse 6:97-106, 1986.

Havassy, B., and Hall, S. Efficacy of urine monitoring in methadone

maintenance: A treatment trial. Am J Psychiatry 138:1497-1500,

1981.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.;

and Badger, G. Achieving cocaine abstinence with a behavioral

approach. Am J Psychiatry 150:763-769, 1993.

Iguchi, M.Y.; Handelsman, L.; Bickel, W.K.; and Griffiths, R.R.

Benzodiazepine and sedative use/abuse by methadone maintenance

clients. Drug Alcohol Depend, in press.

Iguchi, M.Y.; Stitzer, M.L.; Bigelow, G.E.; and Liebson, I.A.

Contingency management in methadone maintenance: Effects of

reinforcing and aversive consequences on illicit polydrug use. Drug

Alcohol Depend 22:1-7, 1988.

Kosten, T.R.; Gawin, F.H.; Rounsaville, B.J.; and Kleber, H.D.

Cocaine abuse among opioid addicts: Demographic and diagnostic

factors in treatment. Am J Drug Alcohol Abuse 12:1-16, 1986.

34
Magura, S.; Casriel, C.; Goldsmith, D.S.; Strug, D.L.; and Lipton, D.S.

Contingency contracting with polydrug-abusing methadone patients.

Addict Behav 13:113-118, 1988.

McCarthy, J.J., and Borders, O.T. Limit setting on drug abuse in

methadone maintenance patients. Am J Psychiatry 142:1419-1423,

1985.

Milby, J.B.; Clarke, C.; Toro, C.; Thornton, S.; and Rickert, D.

Effectiveness of urine surveillance as an adjunct to outpatient

psychotherapy for drug abusers. Int J Addict 15:993-1001, 1980.

Milby, J.B.; Garrett, C.; English, C.; Fritschi, O.; and Clarke, C.

Take-home methadone: Contingency effects on drug-seeking and

productivity of narcotic addicts. Addict Behav 3:215-220, 1978.

Stitzer, M.L.; Bickel, W.K.; Bigelow, G.E.; and Liebson, I.A. Effect of

methadone dose contingencies on urinalysis test results of

polydrug-abusing methadone-maintenance patients. Drug Alcohol

Depend 18:341-348, 1986.

Stitzer, M.L., and Bigelow, G.E. Contingency management in a

methadone maintenance clinic: Availability of reinforcers. Int J

Addict 13:737-746, 1978.

Stitzer, M.L.; Bigelow, G.E.; Liebson, I.A.; and Hawthorne, J.W.

Contingent reinforcement of benzodiazepine-free urines: Evaluation

of a drug abuse treatment intervention. J Appl Behav Anal

15:493-503, 1982.

Stitzer, M.L.; Iguchi, M.Y.; and Felch, L.J. Contingent take-home

incentive: Effects on drug use of methadone maintenance patients.

J Consult Clin Psychol 60:927-934, 1992.

ACKNOWLEDGMENT

Research and manuscript preparation supported by United States Public

Health Service grants DA04104, R18 DA06120, and T32 DA07209

from the National Institute on Drug Abuse.

35
AUTHORS

Maxine L. Stitzer, Ph.D.

Professor of Psychiatry and Behavioral Sciences

Behavioral Pharmacology Research Unit

Francis Scott Key Medical Center

5510 Nathan Shock Drive

Baltimore, Maryland 21224

Martin Y. Iguchi, Ph.D.

Assistant Professor of Mental Health Sciences

Hahnemann University School of Medicine

Department of Mental Health Sciences

Mail Stop 984

Broad and Vine Streets

Philadelphia, Pennsylvania 19102

Michael Kidorf, Ph.D.

Assistant Professor of Psychiatry and Behavioral Sciences

Southeast Baltimore Drug Abuse Treatment Program

Francis Scott Key Medical Center

5510 Nathan Shock Drive

Baltimore, Maryland 21224

George E. Bigelow, Ph.D.

Professor of Psychiatry and Behavioral Sciences

Behavioral Pharmacology Research Unit

Francis Scott Key Medical Center

5510 Nathan Shock Drive

Baltimore, Maryland 21224

36
Clinicwide and Individualized

Behavioral Interventions in Drug

Dependence Treatment

John Grabowski, Howard Rhoades, Ronith Elk, Joy Schmitz,

and Daniel Creson

INTRODUCTION

Behavioral Approaches

Behavioral interventions for treatment of drug dependence have been

developed over the last three decades. They involve systematic

manipulation of a broad range of treatment conditions and are

important for both understanding and treating features of these

disorders. Their utility resides in the focus on drug-seeking and drugtaking, collection of specific data on individual patterns of drug

dependence and abuse, and adapting the elements of treatment to the

patients’ needs. Behavioral approaches also emphasize strategies that

actively extend to the patients’ everyday life, thereby assuring that

behavioral change will endure after treatment ends. This is best

represented by the work of Higgins and Budney (1993).

The terms “behavioral intervention,” “behavior modification,”

“behavior therapy,” and “behavioral treatment” often are used

interchangeably and describe a variety of therapeutic elements. Each

originally emphasized some concepts over others. While cognitive

therapies presume that changing speech and “thinking” changes

behavior, behavioral approaches focus on more tangible representations

of behavior. All derive from the underlying framework that assumes

that altering relationships between behavior and its environmental

determinants is critical to change. Thus, for example, Childress and

colleagues (1993) focus on behavior following a model originally

proposed for application to drug abuse by Wikler (1948) and O’Brien

(1977, 1991). Changes in responses are presumed to contribute to

change in other behaviors such as drug-seeking and drug-taking. Hunt

37
and Azrin (1973), Stitzer et al. (1985), Bigelow et al. (1984), Higgins

and coworkers (1992), Higgins and Budney (1993), and others focused

on operant, or instrumental, behavior based on a model explicated by

Skinner (1953). Modification of the behaviors of drug-seeking and

drug-taking is presumed to alter physiological and cognitive correlates.

Each approach emphasizes specific techniques and is derived from

observations and assumptions about determinants of drug abuse. The

unifying strategy is detailed analyses of specific events surrounding

drug abuse and application through regimens designed to alter

measurable behavior.

Within this framework, drugs of abuse are considered to serve as

reinforcers, and in that regard they share many of the same

characteristics of other events sustaining behavior. Drug-taking is

considered to be an orderly behavior that results from the interaction of

fundamental biologic and behavioral processes. These perspectives

have fostered innovative treatment interventions that focus on the

interplay of environmental, behavioral, and pharmacological factors

and have been the focus of other National Institute on Drug Abuse

(NIDA) reviews (e.g., Krasnegor 1979; Thompson and Johanson 1981;

Grabowski et al. 1984; Ray 1988). A critical feature of these efforts is

the focus on the relationship between drug-taking and its consequences

and, in turn, on establishing a similarly persistent relationship between

treatment-oriented behavior and its consequences and ensuring that

behavioral change endures.

Explicit application of behavioral approaches has made only limited

inroads in traditional treatment environments (e.g., Thompson et al.

1984; Schuster and Silverman 1993), despite extensive research and

positive findings indicating unique contributions. Unfortunately, to the

extent that behavioral interventions have been acknowledged, they

often are linked to the elimination of “problem behaviors,” while other

therapeutic strategies are proposed to form the basis for developing

positive behaviors. For example, Woody and colleagues (1984)

described behavioral interventions in terms of loitering, gun toting, and

drug dealing, while psychotherapy was viewed as the intervention of

choice for achieving positive goals, The work of Crowley (1984) and,

more recently, of Higgins and Budney (1993) points to use of a

spectrum of combined therapeutic elements to develop adaptive

behaviors.

38
All Clinics Have Contingencies

Many clinicians do not refer to their techniques as behavioral

interventions, while others simply ignore or eschew behavioral

approaches. However, the very character and framing of therapy

dictates that the principles are used, labeled or not.

Behavior therapists often refer to “contingencies for reinforcement.”

These specify the relationship between behavior and consequences.

Thus, in every clinic, certain behaviors have consequences even if that

reaction is punishment or inaction. Typically, contingencies are not

recognized or manipulated in a systematic fashion directed at

enhancing treatment. The authors’ thesis is that these often-unspecified

contingencies should be made explicit and consistent with treatment

goals, then systematically applied. The point of application may range

from a single behavior of an individual to an entire treatment system

(Thompson et al. 1984).

This chapter illustrates first that common elements of standard

treatment settings can be addressed readily from a behavioral

perspective rather than being ignored or considered annoyances of

clinical systems. The behavioral-environmental features of studies

described here were designed, in part, to explicate interventions in the

context of standard clinic procedures. The chapter also describes

successive levels of increasingly specific and individualized

applications of behavioral approaches. Studies will be summarized

with reference to data on clinic function, take-home doses of

medications, group contingencies, and, finally, individualized

interventions for specific behavioral problems. A major goal of this

chapter is to describe strategies that permit standard drug abuse

treatment clinics to operate more effectively (also see Elk et al., in

press-a).

GOALS AND IMPLEMENTATION

The goal of implementing clinicwide contingencies is to provide a

systemic and systematic foundation for maintenance of treatmentoriented behavior while reducing problems considered endemic and

integral to clinics, drug abuse treatment, and the patient population.

39
Global fixed contingencies for reinforcement and punishment of a

variety of behaviors, both adaptive and maladaptive, can be

implemented. Thus, for example, many clinics have provisions for gun

toting, loitering, and drug dealing, but they should not be the foremost

considerations of treatment. In fact, they can be framed as clinicwide

contingencies sustaining adaptive behaviors. These treatment-oriented

behaviors include arriving on time, remaining only for necessary

activities, complying with the regimen(s), completing necessary

paperwork, providing blood and urine samples when required, and

generally using the clinic as a treatment site. This goal is dependent

on the clarity of the contingencies and the consistency of their

application and requires no more effort than implementation of

traditional systems.

Implementation of manipulated contingencies common to a group of

patients similarly requires little more effort than other commonly used

formulae. An example is the use of take-home doses of methadone

provided contingent on opiate- or cocaine-free urine samples to modify

behavior. A patient who does not use other opiates in one week may

receive a specified number of take-home doses in the next week.

Conversely, use of opiates during a week when take-home doses of

methadone are available produces a requirement for daily visits (no

take-home doses) in the subsequent week. This contingency for all

patients receiving methadone can be expected to produce behavioral

change in some members of the larger group when systematically

applied. Lack of change in behavior of other patients dictates the need

for additional or alternative strategies similarly implemented for a

subset of patients. The advantage of this dynamic approach resides in

systematic collection of information that then determines modifications

of the treatment contingent on specific patient behaviors. Surprisingly,

these techniques are commonly thought to be the unique province of

research-oriented clinics. Yet they can be readily applied, and their

absence in standard treatment clinics may reduce treatment efficacy.

The next level of individualized contingencies in treatment has two

stages that may be viewed as fixed contingencies applied to the

behavior of individuals or as more refined variable-shaping procedures

that are adjusted repeatedly based on one or more individual behavioral

patterns. These may be more labor-intensive interventions, but they

are no different from the development of detailed individualized

40
treatment plans. Based on intake data, individualized elements of

treatment can be prescribed. This orientation provides for sequential

implementation of the elements of treatment. For example, elimination

of cocaine use in a pregnant, drug-abusing female may be achieved by

providing reinforcers for each successive day for which quantitative or

semiquantitative urine screens indicate reduced cocaine use.

Compliance with a rigorous medication regimen for a tuberculosis-

(TB-) positive male and concurrent reduction in cocaine use may be

similarly tailored on an individual basis.

The procedures can be implemented sequentially or concurrently.

Patients first may be exposed to the general requirements and

successively to the specific approaches. Alternatively, all levels may

be introduced within days of intake.

IMPLEMENTATION OF CLINICWIDE CONDITIONS OF

TREATMENT

Basic “Rules”

In the authors’ clinic, which primarily treats cocaine and opiate

dependent patients, the basic contingencies are defined clearly as an

integral part of treatment and treatment research (see table 1). Details

described in this table permit improved strategies for providing

treatment as well as conducting research. Potential subject-patients

participate in an initial telephone screening interview. All procedures

are implemented as they might be at any high-quality health care

facility, and patients are treated accordingly. Meeting the basic criteria

leads to an immediately specified appointment for intake procedures.

The intake process is carefully scheduled and links elements important

to inclusion or exclusion. This assures that less-costly elements are

carried out first so that false positives are screened out early. This

saves patient and staff time as well as money. An initial interview is

followed by a general medical evaluation. The intake process leads to

group assignment and medication dispensing for opiate or cocaine

dependence at the earliest time, often the same day but always within

24 hours.

41
TABLE 1. This table lists issues and behaviors that emerge in most

drug dependence treatment clinics, although which

problems are most frequent is population dependent.

Focus on these issues often interferes with service delivery.

Generic provisions can be added or eliminated as needed.

Positive (“+”) and negative (“-”) consequences must be

clearly stated and systematically applied. The goal is

specification of positive consequences for which the

absence of that consequence is itself unpleasant. Failure

to comply with items 9 and 10 has the consequences of

warnings and potential discharge. Some issues, such as

discussion of accuracy of laboratory drug screen results,

have neither positive nor negative consequences; they are

not open for discussion, just as blood pressure readings

are medical test results generally accepted and not points

for contention.

Examples of Fixed Clinicwide Contingencies for

Patients and the Nature of Consequences

1. Regular attendance for continued treatment+/-

2. Maintain appointment time for counseling+/-

3. Maintain appointment time for medication+/-

4. Complete data and information update forms+/-

5. Return of medication bottles+/-

6. Provide urine samples for drug screens as

scheduled+/-

7. Arrive and depart in reasonable time (“no

loitering”)-

8. Maintain clean air (“no smoking”)-

9. Contribute to a physically healthy clinic (“no

weapons”)-

10. Support the clinic as the sole vendor (“no drug

dealing”)-

11. Responsiveness to chemistry laboratory

findings (“no arguing”)o

42
Patients are provided with medication time options from three 1-hour

periods scheduled daily–early morning, midday, or early evening.

Similarly, a fixed counseling time is determined in consultation with

the patient. All data and information collection activities are scheduled

to reduce inconvenience for the patient. The basic requirements are

described in both the intake and consent procedures and in the first

counseling session. Urine screens, routinely collected under

observation, are described to the patient as essential medical

evaluations for treatment and research. The difficulties of this process

have been eased by using a video recording system with tapes

reviewed daily by nurses rather than using a live micturition monitor.

Finally, there is an inclusive and clearly stated contingency

surrounding treatment; it is that 75 percent of all specified data

collection points and visits must be met for the patient to be

considered to be “in treatment.” This provides the patient some

leeway, assures that there is contact with the provisions of treatment,

provides certainty with respect to sufficient data, and assures a clear

criterion for dropout.

The result of clearly specified contingencies for basic clinic- and

treatment-oriented behavior is that only 5 (of over 700) patients have

been discharged in the last 4 years of operation due to the serious

problems more common in other clinics. The relatively high rate of

compliance independent of individualized treatment contingencies, in

part, may be related to a decent and positive environment in which

treatment is provided. In brief, clearly labeled, systematically applied

contingencies for participation in treatment appear to have a palliative

effect in provision of treatment, even in what is construed to be a

difficult population.

Large-N Studies With Fixed Group Conditions

The goal of the authors’ primary studies has been to examine specific

components of real treatment. The focus of the research is the joint

action of behavioral and pharmacological elements. In a series of

studies, the first step was to examine fixed treatment requirements

involving visit frequency. The question was whether being required to

visit the clinic more frequently (5 days per week) or less frequently

(2 days per week) affected outcome. These requirements meet the

criterion of contingencies for reinforcement to the extent that a

43
patient’s behavior determines whether or not he or she will be

maintained in treatment. They are characteristic of standard treatments

that typically require a fixed number of visits per week to preclude

discharge. Identifying optimal visit frequency is an important issue for

cost and effectiveness.

Two large studies have addressed the role of take-home dose frequency

or visit frequency as a condition of treatment in relation to medication

doses (Grabowski et al. 1992a, 19926; Rhoades et al. 1992a). The

importance of medication dose is clear, and medication dose can be

expected to interact with other features of treatment. The impetus for

examination of take-home dose or visit frequency derives from two

sources. In part, it emanates from findings in behaviorally based

studies indicating that contingent take-home doses can be an effective

reinforcer (e.g., Bigelow et al. 1984). Beyond potential reinforcing

value, this variable was of considerable interest for two pragmatic

reasons. First, it may affect retention, and ultimately success, in

treatment independent of manipulating its frequency in a contingent

manner. Second, and obviously important, the number of visits per

unit time determines the number of patients who can be served by a

clinic within available resources.

In one ongoing study of primary opiate dependent patients (Rhoades et

al. 1992a, two doses of methadone (50 and 80 mg) were examined in

relation to two take-home conditions. Patients received either 2 or 5

take-home doses of methadone each week. Conversely, they were

required to visit the clinic either 5 or 2 days per week. Special

dispensation was obtained from the Food and Drug Administration and

Drug Enforcement Agency to conduct these studies in which takehome requirements other than those provided for by regulation could

be implemented; thus, patients were permitted to have take-home doses

from the beginning of treatment (Rhoades et al. 1992a). In a second

parallel study with primary cocaine-dependent patients (Grabowski et

al. 1992a, submitted), three medication conditions–two fluoxetine

doses (20 mg and 40 mg) and placebo–also were examined in relation

to two visit conditions–two or five per week. While there was no

manipulation of conditions during treatment, the underlying

contingencies for reinforcement prevailed as they do in any clinic.

These studies emulate the conditions of traditional clinics, in which

failure to comply with the requirements could produce discharge or

44
dropout status. Conditions were specified clearly and consistently

implemented. The major independent variables were medication dose

and take-home frequency, while the major dependent measures were

retention and illicit drug use.

The preliminary interim results for retention with primary opiate

dependent patients are presented in figure 1. Methadone take-home

frequency (and hence clinic visit frequency) was clearly a determinant

of retention. Patients receiving more take-home doses remained in

treatment for longer periods. Opiate-positive urine results did not

differ as a function of frequency within groups at the same methadone

dose, but they did differ across the two dosage levels. Opiate-positive

urine screens were less frequent, occurring at a rate of about 10

percent, in patients receiving the higher methadone medication dose;

the higher dose had the expected effect of greater reductions in illicit

opiate use. One of the main results of this study addresses the

question raised by Childress and coworkers (1991) regarding minimum

required conditions in methadone maintenance. In this case, within

identical counseling, drug screen, and other treatment elements, takehome frequency and dose determined retention. Minimum required

conditions are driven, in part, by patient characteristics and goals, but

it is clear that visit frequency can have pronounced effects.

The retention results for the study with primary cocaine dependent

patients are presented in figure 2 and also indicate the importance of

general visit requirements. Clinic visit frequency was a determinant of

retention. Cocaine-positive urine screens did not differ significantly

across groups regardless of fluoxetine dose or visit frequency

(Grabowski et al., submitted).

Framed as either clinic visits or take-home frequency, this variable is a

major and important feature of treatment. It was codified in

methadone regulations and also is typically an issue of discussion with

respect to cocaine-dependent patients. However, it must be noted with

respect to methadone regulations that the requirements are imprecise,

are not optimal, and were not substantially data based. Specifically,

the low (50 mg) and high (80 mg) doses of methadone combined with

high-frequency take-home dose produced the best results with respect

to retention. High-frequency take-home doses and, thus, fewer clinic

45
Subject Retention by Dose and Take-Home Frequency

FIGURE 1. Patients received low- (2/wk) or high- (5/wk) frequency take-home doses of methadone and visited

the clinic either 5 or 2 days/week. Patients in these groups received either 50 mg or 80 mg of

methadone. Retention data are presented as a function of these four conditions.

KEY: HF=high frequency; LF=low frequency; B=baseline
Subject Retention by Dose and Take-Home Frequency

FIGURE 2. Patients received low- (2/wk) or high- (5/wk) frequency take-home doses of methadone and visited

the clinic either 5 or 2 days/week. Patients in these groups received either 20 mg or 40 mg of

fluoxetine or placebo. Retention data are presented as a function of these six conditions.

KEY: HF=high frequency; LF=low frequency; PBO=placebo
visits also had no untoward or differential effects in cocaine-dependent

patients in terms of retention.

There are complexities to the data relevant to treatment. A clinically

important collateral finding emerged with the higher dose of

methadone. While opiate-positive urine screens were less frequent,

cocaine-positive urine screens were more frequent, and this difference

was statistically significant. This does not argue against the use of

higher doses of methadone, which contributes to reduced human

immunodeficiency virus (HIV) transmission risk, but it does indicate

the need for explicit manipulation of contingencies surrounding cocaine

use or, at least, careful adjustment of methadone dosing to reach an

optimal balance (Grabowski et al. 1993).

Placebo was more effective than either dose of fluoxetine within the

take-home condition (Grabowski et al., submitted). An important, but

not surprising, collateral finding (Grabowski et al. 1992a) was that

benzylecgonine-free urine samples at intake were correlated positively

with less drug use during treatment, and, conversely, metabolitecontaining urines at intake were correlated with more drug use during

treatment as a function of take-home condition. Specifically, cocainedependent patients with positive drug screens at intake did less well

(i.e., had more cocaine-positive drug screens) than patients who had

negative drug screens at intake when required to visit less frequently.

This suggests that required level of intervention can be predicted at

intake, and this addresses a patient matching issue. A behavioral

perspective stipulates that consideration be given to fine-tuning and

individualizing the provisions of treatment, with some patients

requiring more visits to the clinic and others fewer.

In combination, it is evident that take-home dose frequency is an

important factor in retention independent of refined systematic

manipulation. Thus, clinicwide contingencies requiring frequent clinic

visits (e.g., 5 or 7 days per week) are arguably less efficacious in terms

of generating long-term treatment-oriented behavior.

48
MANIPULATION OF CONTINGENCIES FOR GROUPS OF

PATIENTS

The clinicwide provisions for contingencies governing consequences

provide a broad-brush approach to increasing the probability of

positive, treatment-oriented behavior. As addressed by the work of

Iguchi and coworkers (1988), contingencies with positive consequences

for drug-free urine screens may have advantages over aversive

consequences in terms of retention. Further, the work described above

and implementation of effective clinic procedures described by Elk and

colleagues (in press-b) suggest that a generally favorable or positive

clinic environment contributes to treatment-oriented behavior. Stitzer

and Kirby (1991) reviewed behavioral approaches for reducing illicit

drug use among methadone patients. This augments an extensive

literature that points to the ease of inclusion of behavioral interventions

in any clinic. Beyond global conditions or contingencies in treatment,

manipulation of contingencies and individualized approaches can be

implemented.

Progressing through the levels of intervention, the authors have

implemented other studies in a manner emulating standard clinic

conditions. For example, the effect of contingent take-home doses of

methadone was examined (Rhoades et al. 19923). This A-B-A design

study examined the effects of (A) two different baseline conditions

(high- and low-frequency take-home) alone for 8 weeks, (B) then

contingent consequences dependent on drug screen results for 12

weeks, and (A) return to the baseline condition for 4 weeks. With the

exception of the return to baseline, this was not unlike the

circumstances that might prevail in a standard clinic attempting to

implement behavioral procedures. That is, patients enter treatment, are

stabilized during the first 8 weeks, and then are placed under an active

behavior-dependent contingency.

Thirty patients were assigned randomly to one of two groups and

received 70 mg of methadone as a maintenance dose. Patients in one

group initially received five take-home doses per week, while the other

group of patients received two take-home doses per week. After 8

weeks, patients were reminded that take-home doses would be

dependent on results of the twice-weekly drug screens in weeks 9-20.

Drug-free urine screens led to high-frequency take-home doses for the

49
following week. Patients were compliant with the basic requirements

of treatment during the first weeks of treatment. They provided data,

attended counseling sessions, and attended the clinic according to the

requirements of their take-home dose regimen. The contingent

arrangement between urine screen results and take-home dose

opportunities was, in this case, ineffective in reducing the number of

drug- (typically cocaine) positive urine screens. This is reflected by

the fact that, for any given week, approximately 80 to 90 percent of

the patients in each of the groups failed to meet the drug-free criterion

and were required to attend the clinic 5 days per week (figure 3).

However, it is equally clear that this study supports the previously

described fixed-condition methadone study in that an early regimen of

frequent take-homes was effective.

Extensive analyses indicated that demographics and intake variables

were not related to presence or absence of responsiveness to this

contingency. Modifications of this procedure likely would have

produced a better result. However, it is clear that the imposition of

this basic contingency for a subgroup of patients did not have a

substantial effect on collateral drug use. This strongly supports the

need for further research to examine factors diminishing or enhancing

effects of such contingencies and explain these results in light of the

extensive manipulations with positive outcomes. While this particular

study does not affirm the previous reports, it does support the view

that contingencies can be implemented readily for large numbers of

patients in the context of other ongoing treatments. This is important,

since a common argument against the use of behavioral procedures is

that they are unduly costly and time consuming. Another important

feature of behaviorally based perspectives is that subsequent

procedures are modified based on current results to identify the most

effective combination of contingencies. The authors are conducting

further work to elucidate determinants of effectiveness of behavioral

interventions in implementing clinicwide procedures. One

consideration is that much of the earlier work involved methadone

patients dependent on benzodiazepines for whom the simple

consequence of drug-screen-dependent take-home doses reduced

collateral drug use. Many of the patients in the present study were

cocaine-dependent, and this disorder may require modification of the

original contingency management take-home strategy.

50
Subjects Receiving High-Frequency Take-Homes

FIGURE 3. In an A-B-A study, one group received low- (2/wk) or high- (5/wk) frequency take-home doses of

methadone for 8 weeks. For 12 weeks, both were placed under a contingency for which negative

urine screens produced the high-frequency take-home (HFTH) conditions in the next week, while

positive urine screens produced the low-frequency take-home (LFTH) condition in the next week.

During the last 4 weeks, the baseline condition was reinstated. Overall, approximately 10-15

percent of the patients in the baseline LFTH and HFTH conditions met the drug-free criterion

during the contingency period.
IMPLEMENTATION OF INDIVIDUALIZED CONTINGENCIES

Clinicwide conditions and manipulated contingencies for specific

behaviors of groups of patients am initial applications that are

implemented readily. The next step towards precision in treatment

includes application of individualized contingencies, both fixed and

adjustable (e.g., Bigelow et al. 1984; Pickens and Thompson 1984;

Boudin 1972).

Like mutating micro-organisms that require variants on an antibiotic

theme, drug dependence is not a unitary invariant problem. Changes

have emerged in drug abuse, collateral disorders, and special

populations that must be treated; these in turn require adjustments in

intervention strategies. Over the past decade, multiple drug use has

emerged describable as concurrent primary drug dependences (e.g.,

opiate and cocaine). Stitzer and Kirby (1991) have alluded to this in

the context of behavioral interventions, and Dunteman and coworkers

(1992) have described predictors of outcome in methadone-maintained

patients who also use cocaine. Homeless patients have become more

common in this population, providing a major challenge in the

development of treatment. Infectious diseases have become intimately

intertwined with drug abuse. HIV has vectors directly and indirectly

related to drug abuse, including infection through dirty needles on one

hand and transmission from drug-abusing partners to non-drug users on

the other hand. TB has reemerged as a major problem, particularly

among drug-using populations. Another major concern that has

emerged is that of drug-abusing pregnant women whose general

repertoire of health behaviors, if not their specific drug of dependence,

may have unalterable detrimental effects on the fetus or their children.

It can be expected that behavioral intervention strategies are well

suited to application to specific problems of patients and that combined

elements may be used to resolve coexisting problems (e.g., Higgins et

al. 1992) in special populations.

Reinforcer Menus

Development of individualized contingencies requires assessment of a

wide range of consequences that may serve to reinforce behavior as

well as aversive consequences that may eliminate a specific behavior.

Schmitz and Grabowski (1992) have used procedures previously

52
described by Stitzer and Bigelow (1978) in identification of potential

reinforcers. This permits individualization of treatments at best or at a

minimum provides an indication of the relative strength of those

reinforcers that one can apply readily. Using the reinforcer menu

approach, the authors have found that some of the readily available

presumed reinforcers may, in fact, be of limited utility (figure 4).

FIGURE 4. Patients were provided with a list of 15 methadone

treatment clinic privileges as potential reinforcers.

Patient preferences were established using this paired

comparisons method. Counselors were given the same list

and asked to complete it with a view to patient

preferences. The solid bar indicates patient preferences,

and the lined bar indicates counselors’ ratings of patient

preferences. The plausible potential reinforcers were

used in clinic programs.

SOURCE: Schmitz et al. 1991

53
Other opportunities or tangibles have been identified that might be

useful but are difficult to provide, In fact, one survey in which both

counselors and patients were queried clearly suggests some

discrepancies between treatment professionals’ views and those of

patients in terms of potential importance of reinforcers (Schmitz and

Grabowski 1992).

The reinforcer menu approach has the obvious benefit of determining

for whom and under what conditions the elements of treatment should

be implemented. A simple determination of patient preferences readily

could be achieved during the course of standard intake procedures at

any clinic. This, in turn, could provide information to the staff guiding

treatment. At the same time, it must be recognized that there may be

disparities between tangibles and opportunities that are stated to be

important and those that alter behavior when inserted into the tripartite

statement of behavior-contingency-consequence. That is, as previously

discussed, take-home doses of methadone may be powerful modulators

of drug-taking under some but not all circumstances, although patients

may report in an initial survey that they are important. Therefore, the

therapist must approach the problems with a view to revision as

needed based on patient goals, preferences, and observed results when

procedures have been implemented.

The identification of a reinforcer is ultimately determined empirically

in its application to a particular problem or the establishment of a new

behavior. Two examples are found in work with patients entering

treatment for drug abuse: those who are positive for TB and female

patients who are pregnant.

TB-Positive Patient Study

Noncompliance often is viewed as a sine qua non of drug-dependent

patients despite the pervasiveness of the problem across therapeutic

disciplines. This is particularly true in the face of unpleasant or timeconsuming treatment requirements. Ironically, strategies for enhancing

compliance are an integral element of behavioral treatment for any

disorder but are rarely labeled as such in research reports. It can be

said that practitioners of behavioral approaches in drug abuse and other

areas of behavior therapy and behavioral medicine have developed a

specialty in treatment compliance as an integral part of their efforts.

54
The absence of explicit reference to this matter results in failure of the

broader clinical community to appreciate this unique contribution.

TB has increased in prevalence both worldwide and in the United

States, and it is specifically more prevalent in the drug-abusing

population than the general population. This can be attributed to a

variety of ancillary factors rather than drug abuse per se. Nevertheless,

the disease presents special problems in the drug abuse treatment

setting. In the authors’ clinic, approximately 8 percent of the patients

tested with the Mantoux procedure have been positive. In addition,

four staff members have become TB positive over the last 3 years. A

positive response requires subsequent chest x-rays and evaluation. In

the absence of active TB, one of several medications must be

administered for 6 months. All of these agents are potentially

hepatotoxic and may have unpleasant side effects such as nausea and

vomiting. A solution in some clinics is refusal at intake or discharge

of patients found to be TB positive. Working with the Houston

Department of Health and Centers for Disease Control and using

NIDA funding for drug abuse treatment, the authors examined

techniques for assuring compliance with the ioniazide (INH) regimen.

In the first of a series of studies, a fixed-contingency procedure was

used to increase TB treatment compliance in opiate-dependent

methadone patients (Elk et al., in press-a). TB treatment was provided

within the drug abuse treatment clinic. The approach was extremely

conservative and attempted to balance patient needs, staff concerns,

hepatotoxicity, and drug interactions.

Additional consent procedures were presented explicitly addressing the

problems of interaction of INH with alcohol and other drugs. Patients

were stabilized on 70 mg of methadone for 2 weeks, and baseline data

of drug use were obtained. Methadone was dispensed contingent on

INH ingestion throughout. A contingency also was imposed for which

drug-positive urine screens resulted in 5 mg decreases in methadone

dose, while urine screens indicating no concurrent drug use permitted

the patient to request dosing increases or decreases. The results

indicated that the contingent provision of methadone was appropriate

and effective in enhancing INH-taking behavior, and with one

exception, all patients participated in this treatment regimen (figure 5).

The unexpected high rate of concurrent drug (cocaine) use was

55
FIGURE 5. Opiate-dependent patients with positive Mantoux tests

were enrolled in a study where methadone dosing was

contingent upon INH ingestion. Positive urine screens

resulted in 5 mg methadone dose reductions, while

negative urine screens produced the option of patientcontrolled dose adjustment. The conservative contingency

was used due to concerns of hepatotoxicity. The

contingency produced INH ingestion, but the contingency

did not sustain reductions in drug use or long-term

treatment-oriented behavior. Data for 6 patients are

presented; only one (top left panel) remained for the

entire 6-month course of INH treatment. The others were

discharged from this contingency due to collateral

cocaine use.

KEY: B=baseline; C=contingency. Solid line is methadone dose,

dotted line is opiate use, and dashed line is cocaine use.

SOURCE: Modified from Elk et al. 1992

56
unaffected by the contingency. In effect, patients unable to comply

established a self-imposed detoxification regimen through successive

weeks of positive screens.

On this occasion, the defined intervention produced equivocal results.

However, the careful attention to outcome and details of treatment

inherent in behavioral approaches resulted in changing the basic

contingency. The authors subsequently have intervened with a shaping

procedure directed at systematically decreasing cocaine use by

reinforcing sequential reductions as measured by quantitative

benzyleconine-positive screens (figure 6). This has proven more

successful in reducing risks of hepatotoxicity of INH by reducing illicit

drug use.

Pregnancy Study

Another complex and difficult area is treatment of drug-dependent

pregnant women. Much attention has focused on presumed drugeffect-related mechanisms of problems in fetuses and in newborns

delivered by these women (e.g., Finnegan and Kandall 1992).

Delineating mechanisms is ultimately of both scientific and clinical

importance. However, the absence of clear data on the cause of

problems need not deter implementation of behavioral interventions to

reduce drug use and enhance healthful behaviors in this population.

Again, necessity was the mother of intervention. The University of

Texas Health Science Center Department of Obstetrics requited

assistance with cases of pregnant women who had been using drugs.

Elk and colleagues (1993) developed strategies based in the behavioral

framework. An interim report by Kirby and colleagues (1992)

indicated that while some behavioral change resulted from simple

contingency management procedures, behavior at times changed

independent of contingencies and at other times was refractory to

change (figure 7).

The goals and needs of intervention were multiple, as they were with

TB-positive patients. Patients required prenatal care and information

as well as treatment of drug dependence. The interesting finding

indicated above was that some patients were compliant throughout

when the treatment began, while others struggled with drug use,

57
FIGURE 6.

SOURCE:

Patients with positive Mantoux tests were enrolled. In

these cases, sucessive reductions in cocaine use were

shaped using a monetary reinforcer while sustaining the

INH regimen. This graph shows data for one patient.

These individualized contingencies emphasizing positive

reinforcers were effective in sustaining treatment-oriented

behavior and reducing drug use as reflected by the

benzyleconine level.

Elk et al., unpublished data

58
FIGURE 7.

SOURCE:

Panels A and B represent two patterns of behavior of pregnent female patients in attendance of

the obstetrics and drug clinic and urine screens. The top series (left to right) indicates

compliance when contact was made. The bottom panel indicates good but deteriorating

attendance for drug counseling and prenatal care sessions but continued attendance for urine

screens indicating no drug use; patients received money for urine screens. Some patients quickly

complied with all requirements, others were irregular, and others (not presented here) were

dropped out quickly. Patients were enrolled at different times in gestation, and pregnancy

periods differ, thus total weeks differ. A shaping procedure has since been implemented.

Modified from Kirby et al. 1992
attendance at clinics, and other aspects of prenatal care. For some,

pregnancy itself had a therapeutic effect in a manner similar to that

described by Baile et al. (1982) in smoking cessation efforts with

recent heart attack patients. The behavior of other patients was less

influenced by early efforts with contingencies and presumed substantial

reinforcers.

Elk and colleagues (in press-a) are currently examining specific

interventions for these patients that might effectively override the

behavioral control exerted by circumstances surrounding drug use.

Shaping procedures to reduce cocaine use and enhance attendance in

all elements of obstetric and drug abuse treatment are being

implemented, and development of innovative procedures continues.

The cases of TB patients and pregnant women provide extreme

examples at the individual level of detailed behavioral analysis,

precision in intervention, and mixed results. They also provide

examples of factors controlling behavior that are not accessed readily

by behavioral or other psychotherapeutic approaches. Thus, for

example, the state of pregnancy may alter the behavior of some

women who use drugs and overwhelm the behavioral and

pharmacological determinants inherent in drug use as controlling

factors. Thus, they may simply stop using drugs as the result of

complex experiential and social factors. However, pregnancy is no

more a cure for drug abuse than heart attacks are cures for tobacco

smoking. These changes are not magical reversals, and behavior is

explicable. Like the cigarette smoking case, pregnant women may

cease drug use during pregnancy only to resume postdelivery. Not

uncommonly, a woman may stop using drugs but be generally

noncompliant with other requirements of treatment such as prenatal

care, with equally or more detrimental consequences. Overall,

treatment failures can be as instructive as successes for identifying

specific treatment components leading to eventual successful

intervention and prevention of drug abuse, as has been the case in the

examples of individualized drug abuse treatments for pregnant women

and patients who are TB positive.

60
CONCLUSIONS AND DIRECTIONS

A rationale has been presented for explicit inclusion of behavioral

intervention components in drug abuse treatment. The first goal of

drug dependence treatment is to diminish and ultimately eliminate

behavior sustained by the pharmacological agent and associated social

environmental factors. Achieving initial behavioral change requires

establishing the conditions for positive treatment-oriented behaviors.

Thereafter, the process can be implemented at several levels of

increasingly refined and specific interventions. Enduring change

requires that circumstances be established that sustain behavior not

only beyond the reach of the clinic but beyond the duration of active

therapeutic intervention. It can be argued that a variety of other

factors described, if not explained, by myriad theories and observations

modulate drug-taking, and thus, necessarily, a range of factors

determines the probability of success of any particular treatment

regimen. Nevertheless, achieving behavioral change optimally requires

systematic analysis of behavioral and environmental factors controlling

drug-taking, precise implementation of therapeutic techniques based on

these observations, and perpetuation of these effects. In the concluding

paragraphs, consideration is given to concerns regarding practical

implementation of behaviorally based contingency management

approaches in both research and nonresearch treatments. The studies

that the authors are conducting were not intended to provide guidelines

for clinic management, but they have done so (Elk et al., in press- b),

and the main variables provide important data for major elements of

treatment. Thus, the results will be briefly considered from these

perspectives.

As a pragmatic matter, there is a need for encouraging the view that

clearly stated clinicwide contingencies be prescribed for staff members

and patients. While these are assumed to exist (but may not) by

mutual agreement in many traditional treatment environments, the

history and current circumstances of drug abuse treatment appear to

call for precision in specification of these contingencies, which

typically are framed as clinic rules.

The nature of the consequences must be specified with an emphasis on

the positive consequence, although a combination of positive and

negative consequences may be inherent in any procedure. Certainly,

61
the common standard clinic provision, in which the first-line

consequence is exclusion from treatment, is a self-defeating exercise

akin to suspension of children from school who are in need of

education. In one case, education cannot proceed, and in the other, the

implications are lack of treatment, spread of HIV, and continuing

societal and personal costs. Contriving positive consequences can be

difficult, but it should be the goal. It necessarily begins with the view

of positive behavioral goals rather than a list of “thou shall nots.”

Clinicwide provisions must be institutionalized with little deviation.

Deviations that do occur should be well documented and justified by

both the patient and provider. Failure to meet an appointment time is

rarely accommodated in other treatment or nontreatment settings, but it

is much more commonly accepted in drug abuse treatment, not because

of humanistic concerns, but rather because of the crisis-oriented

provision of service and, perhaps, simple disorganization. If

promptness by patients is not expected, it is not achieved, and patients

who are prompt may be punished because of chaos elsewhere in the

clinic. Where it exists, the lack of adherence to treatment requirements

by patients may be defined in part by the lack of attention by staff

members; the interaction is clear and reciprocal. Failure to implement

the requirements of the clinic serves only to increase the lack of

adherence by the patients.

Related to the preceding points is the requirement that the

contingencies should be viewed as facilitating treatment compliance

and success rather than as arbitrary rules to suppress unwanted

problematic behaviors. The goal is not to regiment these patients

unduly, nor is the treatment based on a belief that they require these

steps while others do not; rather it is to provide a framework for

treatment that is responsive and perhaps an advance over what most

patients receive in health care settings. Further, it simply provides

treatment in accord with other settings and indirectly provides valuable

training to those patients who do not have basic skills such as

promptness that they will need when applying for jobs, attending

school, and engaging in social relationships. Adherence to a schedule

is, for some patients, a notable achievement and should be reinforced

and reciprocated.

62
A structure of hierarchical levels of interventions has been described.

The rationale is twofold. First, it is a logical progression applicable to

any such setting, and successive refinement in the intervention

presumably can produce better results more frequently. Further, while

all patients should expect a generally structured clinic operation, not all

patients require the most refined steps in application.

The second issue is pragmatic: the merit and success evidenced by the

data from intensive behavioral interventions with procedures such as

those used by Higgins and Budney (1993) cannot be argued.

Similarly, Thompson and coworkers (1984) provided a systematic plan

for case management with patients having multiple disorders and

deficiencies. Not all sites will be able to achieve these levels of

intervention immediately due to the paucity of available resources.

Arguments that there is long-term saving are logically meritorious but

practically irrelevant if the immediate resources are not available.

However, the argument of limited resources is insufficient to excuse

failure to implement the most general level of contingencies. Thus, a

hierarchical arrangement of interventions is a realistic initial strategy

from which to begin. Furthermore, some procedures can be adjusted

that would save money or permit redistribution of funds to more

effective ends both within clinics and at the level of Federal

regulations. There is no question that the treatment system can be

enhanced through modifications in delivery based on the best available

data, and methadone regulations provide an excellent example. For

instance, patients are not provided with take-home doses for 90 days.

Data from the authors’ large fixed-condition study and the first phase

of the contingent take-home study suggest that the prevailing

regulations are counterproductive. These same seemingly conservative

regulations require only eight urine samples per year; this is an

obviously inadequate monitoring procedure. The need for appropriate

alternatives in the form of more frequent screens with systematic

contingencies is clear, and these ends can be achieved by enhancing

the standard of care rather than adding regulation. Whenever possible,

clinics should strive for the successive levels of implementation, with

counseling sessions serving as the basis for behavioral data collection

to the end of developing optimal interventions through as many levels

as the clinic’s resources permit.

63
With respect to the results of the authors’ projects, a few noteworthy

features will be mentioned. The data suggest that the context of

clinicwide contingencies must be considered. For example, the effort

to expand on those contingencies described in the literature over the

years suggest that refinement of provisions such as contingencies based

on take-home doses may be necessary, and several sources for these

problems have been mentioned.

The data presented in this paper add information to respond to

questions raised by Childress and colleagues (1991) regarding

conditions of methadone treatment and those pointed to by McLellan

and Alterman (1991) concerning patient matching and levels of

treatment. In two studies, one with primary opiate-dependent patients

and the other with primary cocaine-dependent patients, differences in

retention in treatment were clearly evident as a function of visit

frequency and as a function of intake urine screen results. The

consequence of visit frequency itself appears to be “dose

dependent”–that is, dependent on the dose of visits required or takehome opportunities permitted.

Attention to the diverse problems of patients and the encompassing

treatments such as those described by Higgins et al. (1992) and

Higgins and Budney (1993) is important. However, researchers must

not lose sight of other factors more closely related to drug-taking and

medications. This is exemplified by the finding that other drug-taking

(e.g., cocaine use) must be closely monitored, since a valuable and

important therapeutic remedy such as higher methadone dose may have

untoward consequences in increased use of another drug. This requires

attention to balancing interventions, as is true in all composite

therapeutic regimens. This further strengthens the argument that

creative and effective contingency management regimens must be

developed.

The last of these points addresses the issue-perhaps the caution-that

the strength of behavioral interventions resides in their continuing

requirement of evaluation and reevaluation of treatment conditions and

expected behavioral change. Thus, excessive claims about procedures

can be damaging. For example, in the area of evaluation, reinforcer

menus provide a patient’s statement about preferences; patients in

treatment for substance abuse disorders are likely to be no worse than

64
other patients in their self-report, but they certainly are no better.

Thus, care must be used in application of self-report data. Further,

improvement in data analysis capabilities is needed to determine the

valid interpretations of such measures (e.g., Rhoades et al., in press).

Caveats must accompany claims of utility, and variation in

requirements may emanate from patient characteristics and treatment

setting. Similarly, contingent take-home doses generally have been

considered to be extremely effective reinforcers, but the authors’ data

suggest they are helpful but variable. That is, they are likely to be

variable across time, setting, and form of implementation, while fixed

conditions can have substantial effect but do not have the flexibility

required to adapt to the needs of specific patients. Thus, the principles

and procedures of behavioral interventions should be encouraged rather

than an invariant set of prescriptions.

A final thought concerns divergence in the area of substance abuse

disorders, which is perhaps no more or less than that in other areas of

psychology and psychiatry. Behavior appears, after all, to be

everyone’s domain, and the number of theories and strategies for

changing behavior often seems to approximate the number of

practitioners. This makes communication difficult. The goal of

standardizing the language and orientation of interventions is not

predicated on presumed common etiology or sanctity of terms. Rather

it is based in the assumption that progress in the development of

efficacious treatment of substance abuse disorders is very much

dependent on communication and replication. McLellan and Alterman

(1991) have argued the need for prospective studies with common

rules if the goal of identification of predictors is to lead to successful

matching of patients to treatment. Similarly, the structure and

processes of treatment should be described in common terms to permit

ready comparison across interventions. The behavioral framework

seems well suited to meeting this need. The need for research and

application is clear.

The constellation of drug-seeking and drug-taking provides an example

of a disorder characterized by interactions of physiological, behavioral

and environmental elements. It thus seems appropriate that

interventions rely heavily on systematic application of a behavioral

framework that has been demonstrated to be efficacious in a spectrum

of biobehavioral disorders.

65
REFERENCES

Baile, W.F.; Bigelow, G.; Gottlieb, S.H.; Stitzer, M.; and Sacktor, J.D.

Rapid resumption of cigarette smoking following myocardial

infarction: Inverse relation to MI severity. Addict Behav 7:373-380,

1982.

Bigelow, G.; Stitzer, M.; and Liebson, I. The role of behavioral

contingency management in drug abuse treatment. In: Grabowski,

J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions

in Drug Abuse Treatment. National Institute on Drug Abuse

Research Monograph 46. DHHS. Pub. No. (ADM)84-1282.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

pp. 36-52.

Boudin, N. Contingency contracting as a therapeutic tool in

deceleration of amphetamine use. Behav Ther 3:604-608, 1972.

Childress, A.R.; Hole, A.V.; Ehrman, R.N.; Robbins, S.J.; McClellan,

A.T.; and O’Brien, C.P. Cue reactivity and cue reactivity

interventions in drug dependence. In: Onken, L.S.; Blaine, J.D.;

and Boren, J.J., eds. Behavioral Treatments for Drug Abuse and

Dependence. National Institute on Drug Abuse Research

Monograph 137. NIH Pub. No. 93-3684. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1993. pp. 73-95.

Childress, A.R.; McLellan, A.T.; Woody, G.E.; and O’Brien, C.P. Are

there minimum conditions for methadone maintenance to reduce

intravenous drug use and AIDS risk behaviors. In: Pickens, R.;

Leukefeld, G.; and Schuster, C.R., eds. Improving Drug Abuse

Treatment. National Institute on Drug Abuse Research Monograph

106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1991. pp. 167-177.

Crowley, T. Contingency contracting treatment in doctors, nurses, and

dentists. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds.

Behavioral Interventions in Drug Abuse Treatment. National

Institute on Drug Abuse Research Monograph 46. DHHS Pub. No.

(ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1984. pp. 68-83.

Dunteman, G.; Condelli, W.; and Fairbank, J. Predicting cocaine use

among methadone patients: Analysis of findings from a national

study. Hosp Community Psychiatry 43(6):608-611, 1992.

66
Elk, R.; Grabowski, J.; Rhoades, H.; and McLellan, A.T. A substance

abuse research-treatment clinic: Effective procedures and systems.

J Subst Abuse Treat, in press-a.

Elk, R.; Grabowski, J.; Rhoades, H.; Schmitz, J.; and Spiga, R.

“Shaping by Successive Approximation: An Innovative Treatment

of Cocaine Abuse.” Paper presented at the 55th Annual Meeting of

the College on Problems of Drug Dependence, Toronto, Canada,

1993.

Elk, R.; Grabowski, J.; Rhoades, H.; Spiga, R.; Schmitz, J.; and

Jennings, W. Compliance with tuberculosis treatment in methadone

maintained patients: Behavioral interventions. J Subst Abuse Treat,

in press-b.

Finnegan, L.P., and Kandall, S.R. Maternal and neonatal effects of

alcohol and drugs. In: Lowinson, J.H.; Ruiz, P.; Millman, R.B.;

and Langrod, J.G., eds. Substance Abuse: A Comprehensive

Textbook. 2d ed. Baltimore: Williams and Wilkins, 1992.

pp. 628-656.

Grabowski, J.; Elk, R.; Kirby, K.; Cowan, K.; and Rhoades, H.

Fluoxetine and behavioral factors in treatment of cocaine

dependence. In: Harris, L., ed. Problems of Drug Dependence

1991. Proceedings of the 53rd Annual Scientific Meeting, The

Committee on Problems of Drug Dependence, Inc. National

Institute on Drug Abuse Monograph 119. DHHS Pub. No.

(ADM)92-1888. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1992b. p. 362.

Grabowski, J.; Elk, R.; Rhoades, H.; Cowan, K.; Schmitz, J.; and

Kirby, K. “Fluoxetine Dose, Visit Frequency, and Severity in

Cocaine Dependence Treatment.” Paper presented at the Annual

Meeting of the American Psychological Association, Washington,

DC, 1992a.

Grabowski, J.; Rhoades, H.; Elk, R.; Schmitz, J.; and Creson, D.

Fluoxetine in treatment of a heterogeneous population of cocaine

dependent patients. Am J Psychiatry, submitted.

Grabowski, J.; Rhoades, H.; Schmitz, J.; Elk, R.; and Creson, D.

Methadone dose, cocaine and opiate abuse. Am J Psychiatry

150:674, 1993.

Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral

Interventions in Drug Abuse Treatment. National Institute on Drug

Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

67
Higgins, S.T., and Budney, A.J. Treatment of cocaine dependence

through the principles of behavior analysis and behavioral

pharmacology. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds.

Behavioral Treatments for Drug Abuse and Dependence. National

Institute on Drug Abuse Research Monograph 137. NIH Pub. No.

93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1993. pp. 97-121.

Higgins, S.; Delany, D.; Budney, A.; Bickel, W.; Hughes, J.; Foerg, F.;

and Fenwick, J. A behavioral approach to achieving initial cocaine

abstinence. Am J Psychiatry 148(9):1218-1224, 1992.

Hunt, G., and Azrin, N. A community reinforcement approach to

alcoholism. Behav Res Ther 11:91-104, 1973.

Iguchi, J.; Stitzer, M.; Bigelow, G.; and Liebson, I. Contingency

management in methadone maintenance: Effects of reinforcing and

aversive consequences on illicit polydrug use. Drug Alcohol

Depend 22:1-7, 1988.

Kirby, K.; Andres, R.; Bhatt, P.; Davis, M.; Spiga, R.; Elk, R.; and

Grabowski, J. Behavioral treatments of drug abuse during

pregnancy. In: Technical Report From Addictive Behaviors Clinic

of the Substance Abuse Research Center. (Houston: University of

Texas Health Science Center at Houston, Department of Psychiatry

and Behavioral Sciences) no. 3:1-10, 1992.

Krasnegor, N.A., ed. Behavioral Analysis and Treatment of Substance

Abuse. National Institute on Drug Abuse Research Monograph 25.

DHHS Pub. No. (ADM)79-839. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1979.

McLellan, A.T., and Alterman, A. Patient treatment matching: A

conceptual and methodological review with suggestions for future

research. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds.

Improving Drug Abuse Treatment. National Institute on Drug

Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991.

pp. 114-135.

O’Brien, C.P.; Childress, A.R.; and McLellan, A.T. Conditioning

factors may help to understand and prevent relapse in patients who

are recovering from drug dependence. In: Pickens, R.; Leukefeld,

G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment.

National Institute on Drug Abuse Research Monograph 106. DHHS

Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1991. pp. 293-312.

68
O’Brien, C.P.; Testa, T.; O’Brien, T.J.; Brady, J.P.; and Wells, B.

Conditioned narcotic withdrawal in humans. Science 195:1000-

1002, 1977.

Pickens, R., and Thompson, T. Behavioral treatment of drug

dependence. In: Grabowski, J.; Stitzer, M.; and Henningfield, J.,

eds. Behavioral Intervention Techniques in Drug Abuse Treatment.

National Institute on Drug Abuse Research Monograph 46. DHHS

Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1984. pp. 53-67.

Ray, B., ed. Learning Factors in Substance Abuse. National Institute

on Drug Abuse Monograph 84. DHHS Pub. No. (ADM)88-1576.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988.

Rhoades, H.; Elk, R.; Grabowski, J.; and Cowan, K. “Effect of

Changing Clinic Visit Frequency Contingent on Urine Screens:

Drug Use Among Methadone Patients.” Paper presented at the 54th

Annual Meeting of the College on Problems of Drug Dependence,

Keystone, CO, 19923.

Rhoades, H.; Elk, R.; Kirby, K.; Cowan, K.; and Grabowski, J. Joint

action of methadone doses and take-home frequency in treatment

compliance. In: Harris, L., ed. Problems of Drug Dependence

1991. Proceedings of the 53rd Annual Scientific Meeting, The

Committee on Problems of Drug Dependence, Inc. National

Institute on Drug Abuse Monograph 119. DHHS Pub. No.

(ADM)92-1888. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1992a. p. 453.

Rhoades, H.M.; Grabowski, J.; Elk, R.; and Cowan, K. Factor

stationarity and invariance of the POMS in cocaine patients.

Pscyhopharmacol Bull, in press.

Schmitz, J.M., and Grabowski, J. An assessment of the potential

reinforcing value of privileges in methadone maintenance program.

In: Harris, L., ed. Problems of Drug Dependence 1991.

Proceedings of the 53rd Annual Scientific Meeting, The Committee

on Problems of Drug Dependence, Inc. National Institute on Drug

Abuse Monograph 119. DHHS Pub. No. (ADM)92-1888.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992. p.

421.

69
Schuster, C.R., and Silverman, K. Advancing the application of

behavioral treatment approaches for drug dependence. In: Onken,

L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for

Drug Abuse and Dependence. National Institute on Drug Abuse

Research Monograph 137. NIH Pub. No. 93-3684. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. pp. 5-17.

Skinner, B.F. Science and Human Behavior. New York: Macmillan,

1953.

Stitzer, M., and Bigelow, G. Contingency management in a methadone

maintenance program: Availability of reinforcers. Int J Addict

13(5):737-746, 1978.

Stitzer, M.; Bigelow, G.; and McCaul, M. Behavior therapy in drug

abuse treatment: Review and evaluation. In: Ashery, R., ed.

Progress in the Development of Cost-Effective Treatment for Drug

Abusers. National Institute on Drug Abuse Research Monograph

58. DHHS Pub. No. (ADM)85-1401. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1985. pp. 31-50.

Stitzer, M., and Kirby, K. Reducing illicit drug use among methadone

patients. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds.

Improving Drug Abuse Treatment. National Institute on Drug

Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp.

178-203.

Thompson, T., and Johanson, C.E., eds. Behavioral Pharmacology of

Human Drug Dependence. National Institute on Drug Abuse

Research Monograph 37. DHHS Pub. No. (ADM)81-1137.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1981.

Thompson, T.; Koemer, J.; and Grabowski, J. Brokerage model

rehabilitation system for opiate dependence: A behavioral analysis.

In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds.

Behavioral Interventions in Drug Abuse Treatment. National

Institute on Drug Abuse Research Monograph 46. DHHS Pub. No.

(ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1984. pp. 131-146.

Wikler, A. Recent progress in research on the neurophysiologic basis

of morphine addiction. Am J Psychiatry 105:329-338, 1948.

70
Woody, G.E.; McLellan, A.T.; and O’Brien, C.P. Treatment of

behavioral and psychiatric problems associated with opiate

dependence. In: Grabowski, J.; Stitzer, M.; and Henningfield, J.,

eds. Behavioral Interventions in Drug Abuse Treatment. National

Institute on Drug Abuse Research Monograph 46. DHHS Pub. No.

(ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1984. pp. 23-25.

ACKNOWLEDGMENTS

The treatment research projects described here were funded by

National Institute on Drug Abuse grant DA 6143, a Houston

Department of Health/CDC contract for TB interventions to Dr.

Grabowski, and a University of Texas Health Science Center “New

Projects Initiative” grant to Drs. Grabowski and Schmitz and the

Department of Psychiatry and Behavioral Sciences, University of Texas

Health Science Center at Houston.

AUTHORS

John Grabowski, Ph.D.

Professor of Psychiatry and Behavioral Sciences

and

Director

Substance Abuse Research Center

Howard Rhoades, Ph.D.

Assistant Professor of Psychiatry and Behavioral Sciences

Ronith Elk, Ph.D.

Assistant Professor of Psychiatry and Behavioral Sciences

Joy Schmitz, Ph.D.

Assistant Professor of Psychiatry and Behavioral Sciences

71
Daniel Creson, M.D., Ph.D.

Professor of Psychiatry and Behavioral Sciences

Substance Abuse Research Center

Department of Psychiatry and Behavioral Sciences

University of Texas Health Science Center at Houston

1300 Moursund

Houston, Texas 77030

72
Cue Reactivity and Cue

Reactivity Interventions in Drug

Dependence

Anna Rose Childress, Anita V. Hole, Ronald N. Ehrman,

Steven J. Robbins, A. Thomas McLellan, and

Charles P. O’Brien

INTRODUCTION

Jimmy* pulls out of the graveled driveway onto the smooth asphalt

surface of the road. It feels so good to drive again after the long

months in “rehab.” No heroin use in over 6 months. “Not bad,” he

congratulates himself. But as he takes the exit into the old

neighborhood, his bowels begin to growl. He breaks out in sweat,

gripping the steering wheel and trying to ignore the raw, acid taste in

the back of his throat. Yawning, eyes watering, he feels mounting

panic, and the desire for drugs begins to burn in the pit of his stomach.

“So much for good intentions,” he mutters, turning toward a familiar

alley and the drug that will make everything right again.

Dennis leaves his cocaine therapy group full of energy. “I’ve got 30

days clean, and now I’m going for 90!” he yells to a buddy as they

enter their cars. As he leaves the parking lot, a familiar white sedan is

pulling in-Diana’s car; she probably is going to the next group

session. Dennis’ heart begins to pound-gripped by a flood of

memories about the car, where he and Diana had shared so much

cocaine. A wave of intense feeling rushes from the tip of his toes, up

to his head, and back down again. Thoughts racing, desire coursing

through his body, he turns away from the road home, into the night.

As he approaches the familiar buying comer, he can taste the cocaine

in the back of his throat. He is sweating heavily now, ears ringing.

“Just a taste,” he bargains with himself, “just a taste is all I’m going to

buy.”

*Patients’ real names are not used.

73
Though different in some ways, these clinical anecdotes share an

important common feature: certain cues that previously have signaled

the arrival of drug (the sight of a certain neighborhood or car) seem to

set off a host of feelings and reactions. Most commonly, these

reactions include some feeling of arousal and a strong desire for the

drug itself. These responses are of interest because they may prompt

drug-seeking and drug use. This chapter presents a theoretical and

practical approach to these problematic responses. It will focus on two

behavioral strategies used in the authors’ work with opiate and cocaine

patients: passive cue exposure and, more recently, active strategies for

coping with drug craving and arousal.

Relapse and Conditioned Cue Reactivity

Relapse, the return to drug use after a period of abstinence, is a

frustrating problem for patients and clinicians alike. Patients detoxify

and become drug-free but often return to drug use within days or

weeks. How is it that drug-seeking behavior gets started up again after

abstinence has been established, sometimes even for years? It is well

recognized that abused drugs are rewarding (Wise 1988), but this fact

alone does not seem a sufficient explanation for the phenomenon of

relapse; after all, drugs always have their potential rewarding

properties, but animals and people do not administer them all the time.

One possible reason for relapse is that drug-related cues may trigger

strong craving and arousal as described in the clinical anecdotes at the

opening of the chapter. In the authors’ view, the cues may acquire the

“triggering” properties through classical, or Pavlovian, conditioning

(Pavlov 1927). In this type of learning, stimuli reliably signaling

arrival of the drug could acquire the ability to later elicit special drugrelated responses such as those described in the opening paragraphs.

Just as Pavlov’s dogs learned an association between the sound of a

bell and the arrival of food, drug patients may have learned

associations between a large number of stimuli and the effects of their

drugs. If these drug-related responses to drug signals have

motivational properties, they could act as a trigger for drug-seeking

behavior when they are next encountered. Understanding these

responses thus could help explain individuals’ patterns of ongoing drug

use, and controlling or reducing them might help prevent relapse in

patients who manage to become drug-free. Of course, both drug use

74
and relapse are multidetermined, and factors such as the patient’s

psychiatric, social, and employment problems all may play a

contributing role. A general goal of cue reactivity research is to

determine the relative contribution of the responses to drug signals in

setting off drug-seeking behavior.

HISTORICAL AND THEORETICAL NOTES

The study of conditioned cue reactivity began, appropriately, with

Pavlov. He first described the ability of cues that had reliably signaled

the injection of a drug, morphine, to later trigger drug-like responses

that resembled the effects of morphine itself (Pavlov 1927). In the late

1940’s, Wikler (1948) was the first to suggest that certain kinds of

conditioned drug-related responses might play a clinical role in relapse

to drug use. Wikler’s work emphasized the possible role of drugopposite, or “withdrawal-like,” responses in opiate users, hypothesizing

that the experience of these responses might prompt drug-seeking to

alleviate withdrawal discomfort. Subsequent to Wikler, Siegel’s work

(1975, 1976, 1978, 1979) in animals also focused on conditioned drugopposite (called by him “drug-compensatory”) responses, some of

which may play a role in the development of drug tolerance. Stewart

and colleagues (Stewart et al. 1984; deWit and Stewart 1984;

Eikelboom and Stewart 1982) have instead emphasized the potential of

conditioned drug-like states in triggering drug use and relapse. Studies

from these researchers have shown that stimuli likely to “remind”

animal subjects of a previously self-administered drug (e.g., a small

dose of a pharmacologically similar drug or a small “priming” dose of

the drug itself) would lead to a rapid reinstatement of drug selfadministration (deWit and Stewart 1984). In this view, drug-related

cues trigger positive incentive states, “pulling” the user toward the

anticipated drug reward.

Since the 1970’s, the authors’ group at the University of Pennsylvania

has extensively studied cue-triggered responses in both animals and

humans to both opiate- and cocaine-related cues (O’Brien 1975;

O’Brien et al. 1977; Childress et al. 1986a, 1986b, 1988a, 1988b;

Ehrman et al. 1991). The authors have observed both drug-opposite

and drug-like responses in both patient populations, with the type of

responses reported and measured varying somewhat across setting

75
(laboratory versus naturalistic), with perceived differences in drug

availability, and between drug classes (e.g., cocaine patients never

exhibit opiate withdrawal signs).

The responses observed by the authors and by others likely have been

shaped not only by characteristics of the drugs studied but also by

parameters of dose and the timing of response measurement. For

example, though opiate drugs are sedating at higher doses, at lower

doses they have stimulant effects, and these direct effects become

conditioned (Vezina and Stewart 1984). When responses are measured

in relation to signals for drug administration also can make a

difference. Drug-like responses in opiate users, for example, often

occur in the brief interval immediately following a “sham” injection

ritual, but these responses are often both preceded and followed by

withdrawal-like symptoms (Childress et al. 1988b ) .

Even in animal research, in which it is possible to control the

conditioning history of the subject, to know precisely the nature of the

signaling stimulus, and to control for factors that could confuse

interpretation of results, controversies persist about the true nature of

responding to drug signals (deWit and Stewart 1981). In the clinical

situation, where most of these variable are unknowns and controls are

difficult, disagreements about the true nature of the conditioned

response are not surprising. Rather than asking whether responding to

drug signals is drug-opposite or drug-like, it is probably more useful to

ask under what set of conditions each type of responding is most likely

to be seen.

Theoretical interests aside, both drug-opposite and drug-like

conditioned responses could put a patient at risk for drug use. He or

she may be pushed to seek relief from the discomfort of drug-opposite

responses or pulled to seek the reward promised by drug-like

responses. In both cases, movement is in the same direction: toward

the drug and toward potential relapse.

76
WHEN IS A RESPONSE A CONDITIONED RESPONSE?

It is important to realize that reactivity to drug-related cues can occur

for reasons other than conditioning. For example, drug cues (e.g., the

sight of a needle in the injecting paraphernalia) could be more arousing

than neutral cues, even for a non-drug user. Most studies of cue

reactivity do not control for this possibility by assessing the response

of non-drug users to their test cues. Additionally, what if drug users

reacted nonspecifically to cues related to drugs other than the ones

they had used? This possibility can be controlled for by testing

subjects with drug cues unrelated to their drug use history, but it is

rarely done. A recent review by Robbins and Ehrman (1991) fully

describes the criteria for determining whether a response is conditioned

in origin and the controls that are necessary, but often absent, from

conditioning designs and cue reactivity assessments with naturalistic

stimuli.

Most of the work reviewed below simply tested drug-related versus

neutral cues in one type of drug user. Most researchers did not

systematically test cues in non-drug-using controls, nor did they test

identified drug users with cues from another drug class.

Conservatively, the responses from these studies should be considered

simply as reactivity without a conditioning connotation until wellcontrolled studies are done.

A pattern of reactivity easily consistent with a conditioning

interpretation would entail a differential, enhanced responsivity by the

drug user to cues relevant to drug use history (as compared to nondrug cues and to cues unrelated to his or her drug use history), with an

absence of this pattern among a control group of non-drug users. A

recently completed set of studies yielded this pattern of results,

providing the strongest evidence thus far that much reactivity to drugrelated cues is conditioned in origin (Ehrman et al. 1991). The

physiological and subjective reactivity by cocaine patients (n = 15) to

cocaine-related cues was shown to be specific (i.e., dependent upon the

patient’s particular drug use history). They did not react similarly to

opiate cues, and naive non-drug using controls (n = 15) did not show

differential increases in craving or arousal to cocaine-related cues as

compared to non-drug (neutral) or opiate-related cues.

77
CUE REACTIVITY IN THE LABORATORY SETTlNG

Opiate Abusers

Much of the cue reactivity data for opiate abusers comes from

laboratory assessments in which patients were shown both opiaterelated and neutral stimuli and their responsivity then was compared

(Childress et al. 1986a, 1986b, 1988b). Opiate-related stimuli featured

a 10-minute video of simulated drug-buying, drug-selling, and heroin

administration, followed by an opiate-related task in which patients

conducted a mock “cook-up” ritual using a white powder resembling

heroin. (Patients knew the powder was not real heroin and that no real

drugs would be available.) Neutral stimuli consisted of a non-drug

(nature) video equal in length to the drug video and a non-drug task,

playing a computer video game. Physiological measures included

peripheral skin temperature (TEMP), galvanic skin resistance (GSR),

and heart rate (HR). Subjective measures were obtained by asking

each patient to rate, on a 1-to-10 scale, the degree of subjective opiate

high, craving, or withdrawal experienced under each set of stimulus

conditions.

Physiological Responses. Methadone patients (n = 89) showed a

differential responsivity to opiate-related versus neutral stimuli, with

patients generally experiencing significantly greater decreases in TEMP

and in GSR to the drug-related stimuli (Childress et al 1986a , 1988b).

A subsample of detoxifying opiate inpatients showed a generally

similar pattern of physiological reactivity (Childress et al 1988b).

Abstinent opiate abusers (n = 15) who had just returned from a

minimum 30-day inpatient stay also showed a differential responsivity

to opiate-related versus neutral stimuli, again with significantly greater

reductions in TEMP and in GSR to the opiate-related stimuli. HR

changes to opiate-related versus neutral stimuli in opiate abusers were

variable and generally fell short of statistical significance. The

changes in TEMP and GSR are consistent with increases in

physiological arousal to the drug-related stimuli. The degree of change

in physiological responsivity to opiate-related cues often was striking,

with occasional reductions in peripheral skin TEMP of more than

12°F.

78
Subjective Responses. Under laboratory conditions, methadone

outpatients showed increased craving and an increased probability of

withdrawal symptoms in response to opiate-related versus neutral

stimuli (Childress et al. 1986a, 19883). Reports of withdrawal often

were accompanied by yawning, tearing, sneezing, chills, and

complaints of mild nausea or muscle aches. Detoxifying opiate

inpatients had a similar pattern of subjective responsivity, except that

these patients were even more likely (possibly due to the physiological

liability associated with detoxification) than methadone patients to

report withdrawal in response to opiate-related stimuli. Opiate abusers

abstinent for 30 days also reported increased opiate craving to opiaterelated versus neutral stimuli (Childress et al 1986b). The prevalence

of increased craving to opiate-related stimuli in abstinent opioid users

was 90 percent–a rate almost twice that observed in the methadonemaintained patient sample. Across the samples, opiate craving was the

most commonly reported subjective response to opiate-related cues.

Reports of increased subjective high in response to opiate-related

versus neutral cues were relatively uncommon. This pattern may

reflect a bias of the testing situation, as high-like (placebo) responses

to cues are most likely when the patient expects drug (O’Brien et al.

1986; Meyer and Mirin 1979). Patients in the laboratory situation

were told that no real drugs would be involved. They may have been

additionally concerned that reporting “high” responses would raise

suspicion about recent drug use. Most of them, when asked,

acknowledged having such experiences in their natural environment

(see Cue Reactivity in the Natural Environment section).

In sum, opiate patients, whether on methadone, detoxifying, or

abstinent, show a differential reactivity to opiate-related versus neutral

cues. The response pattern usually is characterized by signs of

increased autonomic arousal, signs of increased opiate craving, and,

variably, by reports of withdrawal-like symptoms. This reactivity can

be demonstrated for the majority of patients even in an artificial

laboratory setting with standard (not individualized) stimuli. Further, a

recently completed study shows non-drug users do not exhibit

differential reactivity to opiate-related versus neutral cues (Ehrman

et al. 1991).

79
Using Mood States as Cues. Most of the early work in opiate cue

reactivity used simple external cues. However, it became apparent,

both from the natural environment reports and from direct study, that

internal cues such as mood state could both interact with external cues

and act as powerful drug signals themselves (Childress et al. 1988b).

In one of the earliest observations, an angry mood (resulting from

confrontation with a security guard before the extinction session) was

associated with full reinstatement of previously extinguished

withdrawal symptoms. In a subsequent systematic study, hypnotically

induced mood states, particularly depression and anger, were found to

directly trigger opiate craving and, to a lesser extent, withdrawal-like

symptoms in abstinent opiate abusers (McNair et al. 1971). The

impact of negative moods on craving reliably occurred even before the

addition of external opiate-related cues. Interestingly, most patients in

the sample carried lifetime diagnoses of affective disorder, and thus

they would have had ample opportunity (perhaps through attempts at

self-medication) for depressed mood state to become a reliable signal

for the arrival of drugs.

Cocaine Abusers

Assessments of reactivity to cocaine-related cues have used protocols

very similar to that described for opiate cue reactivity, simply

replacing opiate-related stimuli with cocaine-related videos and

paraphernalia. The cocaine videos and paraphernalia are matched to

the patient’s dominant mode of administration (e.g., cocaine smoking

versus injecting).

Physiological Responses. Assessments in a sample of 51 recently

detoxified cocaine abusers showed a differential reactivity to cocainerelated versus neutral cues, with reliably greater decreases in skin

TEMP and in GSR in response to the cocaine-related cues (Childress

et al. 1988a, 1988b). HR changes were complex and interacted with

the cue modality (video versus task). Interestingly, the reactivity to

cocaine-related cues was equally evident in a subgroup of patients who

had undergone a full 30-day rehabilitation prior to testing (Childress

et al., submitted). The TEMP and GSR findings were replicated in a

second study (Ehrman et al. 1991) that additionally found reliable

increases in HR to cocaine-related versus neutral video stimuli. In a

subsequent protocol, the findings for TEMP and GSR have remained

80
consistent (Ehrman et al., in preparation). The reduction in skin

TEMP to cocaine-related cues can sometimes be dramatic, with

decreases of 10°F or more below baseline levels.

Non-drug-using control subjects do not show these physiological

responses to cocaine-related cues, suggesting the responses do reflect a

history of cocaine use rather than some nonspecifically arousing or

unsettling properties of the cues (Ehrman et al. 1991). The

physiological responses also show a degree of specificity in that

cocaine users do not show them in response to opiate-related cues

(Ehrman et al. 1991).

Subjective Responses. Increased cocaine craving is by far the most

common and robust response to cocaine-related versus neutral stimuli,

and this finding now has been replicated in several protocols (Childress

et al. 1988a, 1988b, submitted; Ehrman et al. 1991, in preparation).

Reports of cocaine craving sometimes are accompanied by the

sensation of a cocaine taste in the back of the throat, a faint ringing in

the ears, a feeling of excitement, or even sexual arousal. Interestingly,

patients often will endorse these concrete drug-like symptoms more

readily than “cocaine high.” Despite education in the authors’ program

about reactions to cues, some patients insist they cannot feel high

because they have not used any cocaine. Reports of cocaine

withdrawal (increases in global self-ratings of cocaine “crash” or

withdrawal on a 1-to-10 scale) to the authors’ laboratory cues also are

relatively uncommon, although some variable effects have been

detected (Childress et al. 1988b, submitted).

In sum, cocaine patients show a differential reactivity to cocainerelated versus neutral cues on both physiological and subjective

measures, and this response is both specific (not occurring to opiaterelated stimuli) and linked to the patient’s drug use history (the pattern

does not occur in non-drug users). These responses were equally

evident even in patients who had completed an intensive 30-day

rehabilitation and usually would be considered “ready for the street.”

This reactivity emerged despite the use of relatively sterile cues, an

artificial laboratory setting, and the patients’ knowledge that real drugs

would not be available. Reactivity evidenced in the laboratory is,

81
therefore, likely to be a conservative estimate of the response to similar

cues in the natural environment.

CUE REACTIVITY IN THE NATURAL ENVIRONMENT

Opiate Abusers

In an early retrospective questionnaire given to 100 methadone

patients, about 60 percent of the patients reported that day-to-day

situations had provoked craving or withdrawal (O’Brien 1975).

Another study based on retrospective interviews with active heroin

users (McAuliffe 1982) reported a lower (27.5 percent) incidence of

withdrawal response to naturally occurring cues. An 8-week

prospective study of naturally occurring craving, withdrawal, and highlike episodes in a small sample of stabilized methadone patients found

that 94 percent (16 of 17) reported episodes of drug craving attributed

to cues. These episodes commonly were attributed to cues such as the

sight of a drug-using friend, hearing drug talk, money, desire for

euphoria, or the occurrence of a depressed mood. Sixteen of seventeen

patients (94 percent) also experienced episodes of withdrawal-like

feelings. Though methadone patients often attributed these

withdrawal-like episodes to physical discomfort or “methadone-dosenot-holding,” some of these episodes may have been triggered by cues

because their occurrence was unrelated to the time since the last dose

of methadone. Seventy-six percent of the methadone patients reported

at least one episode of opiate high-like feelings in response to cues

(Childress et al. 1988b). In a similar prospective study in a small

sample of abstinent opiate abusers, all (8 of 8) had experienced

episodes of opiate craving, averaging 11 episodes per patient for the 8-

week period. In contrast to the frequency of craving episodes, reports

of withdrawal and high-like episodes were relatively uncommon

(Childress et al. 1988b).

Cocaine Abusers

In structured weekly interviews with a research assistant who also

gathered urine samples, cocaine patients readily acknowledged craving

episodes as occurring to cues in the natural environment but

infrequently endorsed high or withdrawal symptoms (Childress 1991a).

82
This pattern may have been influenced by the patients’ concern that

high or withdrawal responses might be viewed as pharmacologic,

rather than conditioned, in origin. In contrast, in detailed interviews

with a clinical psychologist about real-life episodes of cocaine craving

(Childress 1991a), cocaine patients produced extraordinarily consistent

reports of drug-like responses, recounting symptoms of cocaine taste,

ear ringing or buzzing, a hot/cold “rush,” and a feeling of cocaine

high. Thus, the way in which reports are gathered and the person to

whom they are given may affect the nature of the responses reported

by patients as occurring in the natural environment. Endorsements of

craving are best viewed simply as a marker of subjective cue

reactivity-the word may be used by the patient as a global description

for a number of different concrete responses.

The factors that trigger cocaine craving episodes are very similar to

those previously mentioned for opiate patients (Childress 1991b). The

most commonly cited cues involved the sight of a drug-using friend,

money, and depression or other uncomfortable internal state (Childress

1991b). The occurrence of such cue-related episodes also has been

reported by Wallace (1989), who performed a microanalysis of relapse

episodes in a sample of 35 crack cocaine smokers. This study found

that 34 percent of relapse episodes involved exposure to cocainerelated cues (people, places, or things) and 11 percent were connected

with handling money, which can act as a cue. Wallace’s analysis

noted that although most relapse episodes involved multiple

determinants, environmental cues were among the top three

contributors, ranking with “painful emotional states” and “failure to

enter aftercare” as causes for return to cocaine use.

Summary

There now is accumulated evidence that cues that signal opiates or

cocaine can trigger physiological reactivity, and particularly craving, in

opiate or cocaine users. Although some responses to cues are very

drug-specific (e.g., cocaine users never exhibit opiate withdrawal

symptoms), there are also similarities in responsivity across drug

classes. Many of the physiological responses are consistent with

increased arousal, and craving usually is confined to the signaled drug.

Additionally, there is evidence that negative affective states and other

83
internal cues have potency at least equal to external cues in both types

of drug dependence.

That drug-related responses can be elicited reliably in artificial

laboratory settings, where almost everything about the situation–

especially the unavailability of drug-makes them less likely to occur,

attests to their strength. Although most studies of cue reactivity have

not been controlled stringently, some that have (Ehrman et al. 1991)

suggest the origin of much cue reactivity is, indeed, classical

conditioning.

Data from the natural environment (Childress 1991a , Wallace 1989)

lend support to the notion that cue reactivity may be a contributor to

relapse. Both opiate and cocaine patients report frequent episodes of

craving in response to cues, and the responses to cues often are cited

as contributors to relapse.

BEHAVIORAL STRATEGIES

If the reactivity to drug signals plays a role in relapse, then preventing

or reducing this reactivity could be of potential clinical benefit. This

section surveys several different approaches to the problem of drugrelated cue reactivity, with emphasis upon the passive and active

strategies used in the authors’ own work.

Avoidance

Traditional treatment approaches acknowledge the dangers of drugrelated cues for relapse (Washton 1988), generally warning avoidance

of all people, places, and things associated with drug use. This

approach hopes to prevent the craving and arousal triggered by

avoidable external cues. While some cues are avoidable (e.g., a

particular bar or drug-selling comer), many more, unfortunately, are

not. In most urban environments, potential drug signals are

everywhere-from empty crack vials in the street to the television

report of a local drug raid on the evening news. Most patients are

inundated by cues, and a complete avoidance strategy is probably

unrealistic. Even if external cues could somehow be avoided, the

84
reviewed data suggest internal mood cues may be of equal importance,

and they are not avoidable in the usual sense of that word.

Aversive Counterconditioning

Counterconditioning most often is encountered in the form of classical

aversive conditioning, in which an aversive stimulus such as emetine

nausea or shock is paired repeatedly with stimulus properties (smell or

taste) of the abused drug or with actual drug administration (McLellan

and Childress 1985). The goal is a conditioned aversion, such that

stimuli (sight, taste, or smell) associated with the drug will trigger

nausea or repulsion instead of craving or a desire to use.

Although aversive emetine conditioning has been used in the treatment

of many alcoholic inpatients over the past four decades, controlled

studies of its use in opiate and cocaine patients are not yet available.

One study is now underway: Elkins (in press) and his research team

are conducting a comparison of conditioned aversions produced by

chemically induced nausea, by shock, and by hypnotically induced

nausea. The outcome of groups receiving these treatments (in addition

to standard inpatient treatment) will be compared against control

groups receiving milieu therapy or milieu therapy plus relaxation

training. It seems likely that aversive conditioning based on nausea

will be more effective in an alcohol treatment sample than in cocaine

patients: nausea is a consequence of biologic significance for

consummatory behaviors, and it easily can become associated with the

taste and smell cues related to ingestion (Garcia et al. 1966; Rozin

1969). It is unclear whether this same response can be attached to

cues associated with cocaine, which is usually smoked or injected

rather than ingested.

Passive Cue Exposure (Extinction)

If the reactivity to drug signals is based on classical condition, then

presenting the signals not followed by drug should eventually lead to

reduction of the reactivity through the process of extinction. Attempts

to weaken the eliciting power of drug-related conditioned stimuli are

also commonly referred to as cue exposure procedures. These

techniques often are combined with other standard psychosocial

treatments.

85
In Opiate Patients. In a large-scale treatment-outcome study of

extinction in methadone patients (Childress et al. 1988b; McLellan et

al. 1986), a fixed-trials format determined the number of exposures to

each stimulus class (e.g., audio or video). Ten-minute exposures to

eliciting stimuli were preceded by a brief psychotherapy session and

followed by deep relaxation. Patients given up to 35 treatment

sessions showed a significant reduction (extinction) of conditioned

craving in response to the drug-related stimuli across sessions, but

withdrawal symptoms often persisted. Both therapy and therapy plus

extinction groups showed significantly greater clinical improvement at

followup than the control group that received only extra drug

counseling.

Other results from this study were less encouraging. Very few

methadone patients chose to detoxify during the course of the study

despite therapeutic support and small financial incentives, meaning that

the impact of extinction upon relapse to drug use could not be assessed

adequately. Moreover, the outpatient extinction procedure did not

produce complete reduction of withdrawal symptoms, either because

the amount of nonreinforced exposure was inadequate or, perhaps as

likely, because the outpatients would sometimes engage in drug use,

leading to reinstatement of the conditioned responses.

In Cocaine Patients. A recently completed random-assignment

treatment-outcome study (n = 60 patients total, 9 were initial pilots,

and 10 were additional nonrandom subjects) with detoxified cocaine

patients tested the possible benefit of adding passive exposure to

cocaine-related cues (extinction) to either psychotherapy or drug

counseling (Childress et al. 1988a, 1988b, submitted). The

interventions were begun postdetoxification, during a 2-week inpatient

treatment phase, and continued for 8 weeks (2 months) beyond

discharge. Patients who received passive exposure to cocaine-related

cues showed better retention and more cocaine-free urines than control

patients receiving like amounts of therapy or counseling but with

control activities instead of passive cue exposure (Childress et al.,

submitted). Data from the cue exposure phase of this study showed

that repeated exposure (more than 15 hour-long sessions over a 2-week

period) led to a virtually complete reduction in reported cocaine

craving to cocaine cues, but physiological arousal was more persistent.

For example, although skin TEMP reductions to cocaine-related stimuli

86
were diminished after repeated exposure, TEMP still was reduced

below baseline in response to cocaine signals. More disturbing,

patients’ weekly reports of craving episodes showed that they often

still experienced craving in response to cues that could not be

simulated easily in the passive cue exposure paradigm (e.g., sight of an

undressed sexual partner is often a trigger for cocaine craving). These

results indicated that passive cue exposure produced modest benefits

but that generalization of this training to real world cues was

incomplete.

In sum, passive cue exposure effects can be demonstrated, but the

effects are modest and quickly undermined by concomitant drug use.

Using these techniques in a setting where drugs are not available

circumvents this problem but creates another-the problem of

generalization to cues outside the treatment setting.

Active Strategies

The best role for passive cue exposure techniques may be as an

adjunct to strategies that reduce the probability of drug use, even when

drugs are available. Such techniques would permit extinction to occur

by reducing the likelihood of reinstatement effects. Conversely, the

occurrence of extinction might permit a more effective implementation

of coping skills, sometimes undermined by strong cue reactivity.

Positive and potentially synergistic clinical benefits might result.

In an ongoing study attempting this combined approach, cocaine

patients are taught active strategies for reducing the craving and

arousal often triggered by drug-related cues (Childress 1991c ).

Detoxified cocaine outpatients (current n = 16) are assigned randomly

to one of two treatment groups in a 12-week protocol. The treatment

groups combine weekly drug counseling with either active tools (deep

relaxation, behavioral alternatives, negative/positive consequences,

aversive/positive imagery, mastery imagery, and cognitive

interventions) for reducing craving and arousal or with other control

activities (videotapes about family relationships and addiction).

Patients practice the active tools in the presence of a trained therapist,

using them to reduce the craving triggered by recounting (in vivid

sensory detail) a personal craving episode. This approach thus

employs both active strategies and, by repeated use of the craving

87
episodes, an exposure component. Although final outcomes are not yet

available, patients are able to learn these tools and to use them to

reduce the craving triggered by recounting a recent craving episode

(Childress 1991c).

OTHER APPLICATIONS OF CUE REACTIVITY

ASSESSMENTS

To Screen Putative Anticraving Agents

The cocaine epidemic in the United States has prompted an intense

search for medications with anticraving properties (Gawin et al. 1989).

It seems reasonable to ask whether these agents might help block or

reduce the craving and physiological reactivity triggered by drugrelated cues. At least three separate research groups now are using cue

reactivity paradigms to assess the impact of these drugs on cocaine

craving (Ehrman et al., in preparation; Margolin et al. 1990; Kranzler

and Bauer 1990). Thus far, assessments conducted with the putative

anticraving agent amantadine show that craving was unaffected by the

drug, but physiological arousal to cocaine-related cues actually was

increased for patients on amantadine versus those on placebo (Ehrman

et al., in preparation). Cocaine cue-reactivity assessments with

carbamazepine, bromocriptine, and bupropion also are underway

(Ehrman et al., in preparation; Margolin et al. 1990; Kranzler and

Bauer 1990). Since most of the medications are used as part of a

clinical trial, it will be possible to see whether the medication effects

on cue reactivity parallel or predict clinical efficacy. Screening agents

in a few patients with these procedures is far less expensive than a

full-scale clinical trial and may provide some needed initial guidance

in selecting agents that deserve further study.

It is of note that replacement therapies for opiates (methadone) and

cigarette smoking (nicotine polacrilex gum) reduce withdrawal but

leave craving quite intact (Henningfleld and Brown 1987). Whether

specific anticraving pharmacotherapies can be developed remains to be

demonstrated, but cue reactivity assessments could either facilitate this

goal or reveal it to be overly optimistic.

88
To Study the Neurochemical Substrates of Conditioned

States Related to Drug Use

A new and potentially exciting extension of the cue reactivity work is

offered through the recent availability of in vivo brain-imaging

technology. Newly initiated research (Childress 1991a) is attempting

to visualize the neurochemical correlates of craving states induced by

exposure to drug-related cues in cocaine abuse patients. With future

development of radiotracers for multiple neurotransmitter systems, it

should be possible to define the neurochemical and neuroanatomical

substrates for different types of craving. This, in turn, would aid

development of medications that could effectively modify the response

to drug signals.

SUMMARY

Despite a venerable history dating back to Pavlov and countless

testimonials from patients such as those in the opening paragraphs of

this chapter, there is much that remains to be learned about drug

signals and, particularly, about ways of reducing their adverse effects

on human drug users. There is a substantial amount of data showing

increased craving and signs of physiological arousal to drug-related

versus neutral cues in drug users for both drug classes reviewed here.

Additional controlled studies will be useful in refining which responses

among those studied are, in fact, conditioned in origin and therefore

can be subjected reasonably to learning-based interventions. Most

attempts to modify cue responsivity for clinical benefit have met with

only modest success, and there is ample mom for creative, but

controlled, treatment-outcome studies.

In recent years, several other groups have joined in the effort to

understand drug-related cue reactivity, extending the research area to

alcohol and nicotine (Monti et al. 1987; Niaura et al. 1988, 1989;

Cooney et al. 1984; Hodgson and Rankin 1982; Drummond 1990;

Laberg 1990). The interested reader is referred to several additional

reviews of cue reactivity and cue exposure research related to alcohol

and nicotine (Niaura 1988; Drummond 1990; Laberg 1990), opiates

(Powell 1990), opiates and cocaine (Childress et al. 1988b; O’Brien et

al. 1990), and all the preceding areas (Rohsenow et al. 1991).

89
REFERENCES

Childress, A.R. “Integrating Cue Exposure Techniques With Standard

Psychosocial Treatments for Cocaine Dependence.” Paper presented

at National Institute on Drug Abuse Symposium, “Research and

Treatment: Alliance for the 21st Century,” Washington, DC, January

1991c.

Childress, A.R. “Addressing the Problem of Craving and Arousal

Triggered by Drug-Related Cues.” Paper presented at the National

Institute on Drug Abuse/Addiction Research Center Symposium on

Craving, Baltimore, February 27-28, 1991b .

Childress, A.R. “Using Cue Reactivity To Induce Craving and To Find

Strategies for Reducing It.” Paper presented at National Institute on

Drug Abuse Technical Review, “Neurobiological Models for

Evaluating Mechanisms Underlying Cocaine Addiction and Potential

Pharmacological Pharmacotherapies for Treating Cocaine Abuse,”

New Orleans, November 8, 1991a.

Childress, A.R.; Ehrman, R.; McLellan, A.T.; and O’Brien, C.P.

Conditioned craving and arousal in cocaine addiction: A preliminary

report. In: Harris, L.S., ed. Problems of Drug Dependence 1987.

Proceedings of the 49th Annual Scientific Meeting, The Committee

on Problems of Drug Dependence, Inc. National Institute on Drug

Abuse Research Monograph 81. DHHS Pub. No. (ADM)88-1564.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988a.

pp. 74-80.

Childress, A.R.; Ehnnan, R.; MacRae, J.; McLellan, A.T.; and

O’Brien, C.P. “Cue Reactivity and a Cue Exposure Intervention in

Cocaine Dependence.” Manuscript submitted for publication.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Abstinent opiate

abusers exhibit conditioned craving, conditioned withdrawal, and

reductions in both through extinction. Br J Addict 81:655-660,

1986b.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Conditioned

responses in a methadone population: A comparison of laboratory,

clinic, and natural setting. J Subst Abuse Treat 3:173-179, 1986a.

90
Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Classically

conditioned responses in cocaine and opioid dependence: A role in

relapse? In: Ray, B.A., ed. Learning Factors in Substance Abuse.

National Institute on Drug Abuse Research Monograph 84. DHHS

Pub. No. (ADM)88-1576. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1988b. pp. 25-43.

Cooney, N.L.; Baker, L.H.; Pomerleau, O.F.; and Josephy, B.

Salivation to drinking cues in alcohol abusers: Toward the

validation of a physiological measure of craving. Addict Behav

9:91-94, 1984.

deWit, H., and Stewart, S. Reinstatement of cocaine-reinforced

responses in the rat. Psychopharmacology 75: 134-143, 1981.

Drummond, C. Conditioned learning in alcohol dependence:

Implications for cue exposure treatment. Br J Addict 85:725-743,

1990.

Ehrman, R.N.; Robbins, S.; and Childress, A.R. “Amantadine Increases

Physiological Reactivity to Cocaine-Related Cues.” Manuscript in

preparation.

Ehnnan, R.N.; Robbins, S.J.; Childress, A.R.; McLellan, A.T.; and

O’Brien, C.P. Responding to drug-related stimuli in humans as a

function of drug-use history. In: Glennon, R.A.; Jarbe, T.; and

Frankenheim. J., eds. Drug Discrimination: Applications to Drug

Abuse Research. National Institute on Drug Abuse Research

Monograph 116. DHHS Pub. No. (ADM)92-1878. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 231-244.

Eikelboom, R., and Stewart, J. Conditioning of drug-induced

physiological responses. Psychol Rev 89:507-528, 1982.

Elkins, R.L. An appraisal of chemical aversion (emetic therapy)

approaches to alcoholism treatment. Behav Res Ther, in press.

Garcia, J.; Ervin, F.R.; and Koelling, R.A. Learning with prolonged

delay of reinforcement. Psychonomic Sci 5:121-122, 1966.

Gawin, F.H.; Kleber, H.D.; Byck, R.; Rounsaville, B.J.; Kosten, T.R.;

Jatlow, P.I.; and Morgan, C. Desipripramine facilitation of initial

cocaine abstinence. Arch Gen Psychiatry 46:117-121, 1989.

Henningfield, J.E., and Brown, B.S. Do replacement therapies treat

craving? NIDA Notes 1:8-9, 1987.

91
Hodgson, R.J., and Rankin, H.J. Cue exposure and relapse prevention.

In: Hay, W.M., and Nathan, P.E., eds. Clinical Case Studies in the

Behavioral Treatment of Alcoholism. New York: Plenum Press,

1982. pp. 207-226.

Kranzler, H.R., and Bauer, L.O. Effects of bromocriptine on subjective

and autonomic responses to cocaine-associated stimuli. In: Harris,

L.S., ed. Problems of Drug Dependence 1990. Proceedings of the

52nd Annual Scientific Meeting, The Committee on Problems of

Drug Dependence, Inc. National Institute on Drug Abuse Research

Monograph 105. DHHS Pub. No. (ADM)91-1753. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1990. pp. 505-506.

Laberg, J.C. What is presented, and what is prevented, in cue exposure

and response prevention with alcohol dependent subjects? Addict

Behav 15:367-386, 1990.

Margolin, A.; Kosten, T.; Petrakis, I.; Kelly Avants, S.; and Kosten, T.

An open pilot study of bupropion and psychotherapy for the

treatment of cocaine abuse in methadone-maintained patients. In:

Harris, L.S., ed. Problems of Drug Dependence 1990. Proceedings

of the 52nd Annual Scientific Meeting, The Committee on Problems

of Drug Dependence, Inc. National Institute on Drug Abuse

Research Monograph 105. DHHS Pub. No. (ADM)91-1753.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990.

pp. 367-368.

McAuliffe, W.E. A test of Wikler’s theory of relapse due to

conditioned withdrawal sickness. Int J Addict 17:19-33, 1982.

McLellan, A.T., and Childress, A.R. Aversive therapies for substance

abuse: Do they work? J Subst Abuse Treat 2:187-191, 1985.

McLellan, A.T.; Childress, A.R.; O’Brien, C.P.; and Ehrman, R.N.

Extinguishing conditioned responses during treatment for opiate

dependence: Turning laboratory findings into clinical procedures.

J Subst Abuse Treat 3:33-40, 1986.

McNair, D.; Lorr, M.; and Droppleman, L. Manual: Profile of Mood

Stares. San Diego: Educational and Industrial Testing Service, 1971.

Meyer, R.E., and Mirin, A.M. The Heroid Stimulus: Implications for a

Theory of Addiction. New York: Plenum Press, 1979.

Monti, P.M.; Binkoff, J.A.; Abrams, D.B.; Zwick, W.R.; Nirenberg,

T.D.; and Liepman, M.R. Reactivity of alcoholics and nonalcoholics

to drinking cues. J Abnorm Psychol 96:122-126, 1987.

92
Niaura, R.S.; Abrams, D.B.; Monti, P.M.; and Pedraza, M. Reactivity

to high risk situations and smoking cessation outcome. J Subst

Abuse Treat 1:393-406, 1989.

Niaura, R.S.; Rohsenow, D.J.; Binkoff, J.A.; Monti, P.M.; Pedraza, M.;

and Abrams, D.B. Relevance of cue reactivity to understanding

alcohol and smoking relapse. J Abnorm Psychol 97:133-152, 1988.

O’Brien, C.P. Experimental analysis of conditioning factors in human

narcotic addiction. Pharmacol Rev 27:535-543, 1975.

O’Brien, C.P.; Childress, A.R.; McLellan, A.T.; and Ehrman, R.N.

Integrating systematic cue exposure with standard treatment in

recovering drug dependent patients. Addict Behav 15:355-365, 1990.

O’Brien, C.P.; Ehrman, R.; and Temes, J. Classical conditioning in

human opioid dependence. In: Goldberg, S.R., and Stolennan, I.P.,

eds. Behavioral Analysis of Drug Dependence. Orlando, FL:

Academic Press, 1986. pp. 329-356.

O’Brien, C.P.; Testa, T.; O’Brien, T.J.; Brady, J.P.; and Wells, B.

Conditioned narcotic withdrawal in humans. Science 195:1000-

1002, 1977.

Pavlov, I.P. Conditioned Reflexes. London: Oxford University Press,

1927.

Powell, J.; Gray, J.A.; Bradley, B.P.; Kasvikis, Y.; Strang, J.; Barratt,

L.; and Marks, I. The effects of exposure to drug-related cues in

detoxified opiate addicts: A theoretical review and some new data.

Addict Behav 15:339-354, 1990.

Robbins, S.J., and Ehnnan, R. Conditioned factors in alcoholism.

Virginia Merit Review, 1991.

Rohsenow, D.; Niaura, R.; Childress, A.R.; Abrams, R.; and Monti, P.

Cue reactivity in addictive behaviors: Theoretical and treatment

implications. Int J Addict 25:957-993, 1991.

Rozin, P. Central or peripheral mediation of learning with long CSUCS intervals in the feeding system. J Comp Physiol Psychol

67:421-429, 1969.

Siegel, S. Evidence from rats that morphine tolerance is a learned

response. J Comp Physiol Psychol 89:4998-5006, 1975.

Siegel, S. Morphine analgesic tolerance: Its situation specificity

supports a Pavlovian conditioning model. Science 193:323-325,

1976.

Siegel, S. Tolerance to hyperthermic effect of morphine in the rat is a

learned response. J Comp Physiol Psychol 92:1137-1149, 1978.

93
Siegel, S. The role of conditioning in drug tolerance and addiction. in:

Keehn, J.D., ed. Psychopathy in Animals: Research and Clinical

Implications. New York: Academic Press, 1979.

Stewart, J.; deWit, H.; and Eikelboom, R. The role of unconditioned

and conditioned drug effects in the self-administration of opiates

and stimulants. Psychol Rev 91:251-268, 1984.

Vezina, P., and Stewart, J. Conditioned locomotion and place

preference elicited by tactile cues paired exclusively with morphine

in an open field. Psychopharmacol Biochem Behav 20:925-934,

1984.

Wallace, B.C. Psychological and environmental determinants of relapse

in crack cocaine smokers. J Subst Abuse Treat 6:95-106, 1989.

Washton, A. Preventing relapse to cocaine. J Clin Psychiatry

49(1):34-38, 1988.

Wikler, A. Recent progress in research on the neurophysiological basis

of morphine addiction. Am J Psychiatry 105:328-338, 1948.

Wise, R.A. The neurobiology of craving: Implication for the

understanding and treatment of addiction. J Abnorm Psychol

97:118-132, 1988.

ACKNOWLEDGMENTS

The authors’ research was funded by NIDA project DA 03008, by

NIDA Center grant #P50-DA5186, and by a Virginia Merit Review

grant to Charles O’Brien. The material for this chapter was taken,

with modifications, from two sources by the same first author:

“Classically Conditioned Factors in Addiction,” by Childress, A.R.;

Ehrman, R.; and Rohsenow, D.J., in Lowinson, H., and Ruiz, P., eds.

Comprehensive Textbook on Substance Abuse. Baltimore: Williams and

Wilkins, 1992. pp. 56-69, and “Cue Reactivity in Opiate and Cocaine

Dependence,” presented (in Spanish) at the Citran Symposium on Drug

Dependence Treatment, Barcelona, Spain, 1990.

94
AUTHORS

Anna Rose Childress, Ph.D.

Clinical Associate Professor of Psychology in Psychiatry

Anita V. Hole, Ph.D.

Clinical Assistant Professor of Psychology in Psychiatry

Ronald N. Ehrman, Ph.D.

Clinical Assistant Professor of Psychology in Psychiatry

Steven J. Robbins, Ph.D.

Clinical Assistant Professor of Psychology in Psychiatry

A. Thomas McLellan, Ph.D.

Research Professor of Psychology in Psychiatry

Charles P. O’Brien, M.D., Ph.D.

Professor of Psychiatry

Addiction Treatment Research Center

University of Pennsylvania School of Medicine

and

Department of Psychiatry

Philadelphia Department of Veterans’ Affairs Medical Center

Philadelphia, PA 19104

95

Treatment of Cocaine

Dependence Through the

Principles of Behavior Analysis

and Behavioral Pharmacology

Stephen T. Higgins and Alan J. Budney

INTRODUCTION

This report describes a series of prospective and retrospective studies

conducted to examine the efficacy of an outpatient behavioral

treatment for cocaine dependence (Budney et al. 1991; Higgins et al.

1991, 1993a, 1993b, in press-a). The treatment is based on the

scientific principles and conceptual framework of behavior analysis and

behavioral pharmacology. In that framework, use of abused drugs is

considered a special case of operant behavior that is maintained by the

reinforcing effects of the drugs involved. Scientific support for this

behavioral approach to drug abuse stems from the reliable empirical

observation that laboratory animals self-administer most of the same

drugs that are abused by humans (Griffiths et al. 1980; Henningfield et

al. 1986). Cocaine, amphetamines, opioids, sedatives, and ethanol are

readily self-administered by laboratory animals (Young and Herling

1986). Neither a prior history of drug exposure nor physical

dependence is necessary for these drugs to function as reinforcers and

maintain an ongoing pattern of drug self-administration. Effects of

alterations in drug availability, drug dose, response requirement, and

other environmental factors on drug ingestion are orderly and have

generality across a variety of species, including humans, and different

types of drug dependence (Griffiths et al. 1980). Such commonalities

across species and types of drug dependence support a position that the

fundamental causes of drug self-administration and dependence lie at

the level of basic biologic processes common across many species

(Brady 1981; Griffiths et al. 1980; Stitzer et al. 1989).

97
This behavioral model of drug abuse has permitted researchers to

effectively extrapolate and apply to drug dependence scientific

principles already available from research on other types of operant

behavior and has generated a great deal of empirical knowledge

concerning the dynamic role played by environmental and

pharmacological variables in the reinforcing effects of drugs (Goldberg

and Stolerman 1986). That knowledge has important treatment

implications that are applicable to the treatment of cocaine dependence.

The basic strategy is to rearrange the drug user’s environment so that

(1) drug use and abstinence are readily detected, (2) drug abstinence is

positively reinforced, (3) drug use results in an immediate loss of

reinforcement, and (4) the density of reinforcement derived from

nondrug sources is increased to compete with the reinforcing effects of

drugs.

A Behavioral Treatment for Cocaine Dependence

The behavioral treatment described in this report is 6 months in

duration and implements the aforementioned strategy via contingencymanagement procedures (Bigelow et al. 1981; Stitzer et al. 1989)

integrated with counseling from the Community Reinforcement

Approach (CRA) (Sisson and Azrin 1989).

Detection of Drug Use. In order to detect cocaine use and

abstinence, urine specimens are collected under staff observation

according to a fixed monitoring schedule (e.g., Monday, Wednesday,

and Friday). Specimens are screened immediately with an onsite

Enzyme Multiplied Immunoassay Technique (EMIT) (Syva Corp., Palo

Alto, CA). All specimens are tested within several minutes after

collection and screened for benzoylecgonine, a cocaine metabolite.

Failure to submit a scheduled specimen is treated as a cocaine-positive

specimen. This fixed schedule of drug monitoring leaves little

opportunity for undetected cocaine use. At least one randomly

selected specimen each week also is screened for the presence of other

abused drugs, and breath alcohol levels are assessed at the time urine

specimens are collected.

Abstinence Is Reinforced. Contingency-management procedures are

used to reinforce cocaine abstinence. Patients, therapists, and, when

98
possible, significant others are informed of urinalysis results

immediately after testing. During weeks 1-12, specimens negative for

benzoylecgonine earn points that are recorded on vouchers and given

to patients. Points are worth approximately $0.25 each. The first

negative specimen is worth 10 points, or $2.50. The value of vouchers

for each subsequent consecutive negative specimen increases by

5 points (e.g., the second voucher is worth 15 points, the third,

20 points, etc.) To further increase the likelihood of continuous

cocaine abstinence, the equivalent of a $10 bonus is earned for each

three consecutive negative specimens. Submission of a cocainepositive specimen or failure to submit a scheduled specimen resets the

value of vouchers to the initial $2.50 value, from which they can

escalate again. Submission of five consecutive cocaine-negative

specimens following submission of a positive specimen returns the

value of points to where they were prior to the reset. Points cannot be

lost once earned.

Money Is Never Provided Directly to Patients. Instead, vouchers

are used to purchase retail items in the community. A staff member

makes all purchases. Items obtained using the vouchers are quite

diverse and have included ski-lift passes, fishing licenses, gift

certificates to local restaurants, camera equipment, bicycle equipment,

and continuing education materials. Counselors retain veto power over

all purchases. Purchases are approved only if, in the counselor’s

opinion, they are in concert with individual treatment goals of

increasing drug-free prosocial activities. The voucher system is in

effect during weeks 1-12 of treatment, while during weeks 13-24 the

magnitude of the reinforcer is reduced to one Vermont State Lottery

ticket for each cocaine-negative specimen.

Drug Use Results in the Loss of Positive Reinforcement,

Vouchers, lottery tickets, and social reinforcement are withheld when

urinalysis results indicate recent cocaine use.

Reinforcement Density From Nondrug Sources Increased. The

voucher system is designed to increase reinforcement density from

nondrug sources, and aspects of CRA also are used for that purpose.

The CRA procedures are implemented in twice-weekly, 1-hour

counseling sessions for 12 weeks and then once weekly during the

subsequent 12 weeks.

99
Sessions Focus on Four General Issues. First, subjects with a

spouse, friend, or relative who is not a drug abuser and is willing to

participate in treatment receive reciprocal relationship counseling. This

is a validated procedure for instructing dyads how to negotiate for

positive changes in their relationship (Azrin et al. 1973). To integrate

CRA and contingency-management procedures, significant others are

telephoned immediately following each urinalysis test and informed of

results. If the specimen was negative for cocaine, the significant other

engages in agreed-upon activities with the patient. If the result was

positive for cocaine use, the significant other refrains from the

activities but offers assistance to the patient in dealing with difficulties

in achieving abstinence. In recent trials, approximately 80 percent of

patients have had a significant other participate in treatment at some

point during the 6-month treatment period (Higgins et al. 1993a).

Significant others have included spouses or other sexual partners,

parents, siblings, in-laws, and friends. No empirical evidence exists to

indicate that any one type of significant other is better than another.

Second, subjects are instructed how to recognize antecedents and

consequences of their cocaine use. They are counseled to restructure

their daily activities to minimize contact with known antecedents, find

alternatives for the positive consequences derived from cocaine use,

and make explicit the negative consequences of cocaine use. Skills

training is provided to those with specific deficits (e.g., drug refusal,

problem solving, or assertiveness). Patients exhibiting persistent

evidence of depression are provided a behavioral treatment for

depression that is easily integrated with this behavioral treatment for

cocaine dependence. Other problems that may interfere with achieving

cocaine abstinence (e.g., persistent insomnia) also are addressed

through behavioral counseling. Acquired immunodeficiency syndrome

(AIDS) prevention counseling is provided to all patients.

Third, unemployed patients are offered employment counseling (Azrin

and Besalel 1980). Assistance also is provided for those interested in

pursuing educational goals or job changes and those with

miscellaneous practical needs such as financial counseling, alternative

housing, or legal and social services.

100
Fourth, subjects are counseled to develop new recreational activities or

to become reinvolved in those they pursued prior to beginning cocaine

use. Counselors and subjects work together to identify these activities.

This also provides an avenue for integration of the contingencymanagement and CRA components. Vouchers earned through

cocaine-free urine specimens are used to support costs of initiating

these activities.

Treatment is delivered by master’s-level counselors specifically chosen

because they are not trained in traditional approaches to drug and

alcohol counseling. In the authors’ experience, it is difficult to find

master’s-level counselors with experience in behavior therapy. To

date, the authors have had success training rehabilitation counselors,

general adult counselors, and graduate students in clinical psychology

in this approach. Clinical supervision is provided by a doctoral-level

behavioral psychologist at least once weekly, and such close

supervision by someone experienced in the use of behavioral

treatments for substance abuse is necessary for effective application of

this treatment approach.

All patients who meet DSM III-R criteria for alcohol dependence or

report that alcohol use causes problems in their attempts to achieve

cocaine abstinence are offered disulfiram therapy. Disulfiram therapy

is an integral part of the CRA treatment for alcoholism (Sisson and

Azrin 1989). The dose is usually 250 mg/daily unless patients report

being able to consume alcohol at that dose without a reaction. In this

case, the daily dose is increased to 500 mg. Disulfiram ingestion is

observed by clinic staff when patients come for urinalysis monitoring.

Take-home doses are provided for the other days and, if possible, are

ingested in the presence of a significant other in accordance with

disulfiram assurance procedures designed to improve compliance

(Sisson and Azrin 1989).

RESEARCH STUDIES

Behavioral Treatment Versus Drug Abuse Counseling

Nonrandomized Trial. The first study examining the efficacy of this

behavioral treatment in establishing initial cocaine abstinence was

101
conducted with 13 consecutive admissions to an outpatient clinic

(Higgins et al. 1991). Results were compared against data from a

second group of 15 consecutive admissions who received standard

outpatient drug and alcohol counseling from a disease-model

orientation. This study focused on the first 12 weeks of treatment.

Urines were collected on Saturdays in addition to the Monday,

Wednesday, and Friday schedule described above. Because the

disulfiram component of the treatment was just beginning, only one

patient in the behavioral group received disulfiram therapy.

Those in the drug abuse counseling group participated in the same

schedule of urine monitoring as those in the behavioral treatment, but

results were not shared with patients or therapists; patients received $5

per specimen independent of results. The schedule of counseling was

the same as in the behavioral group, but group therapy was

emphasized consistent with the typical format in this approach.

Patients were counseled that cocaine addiction was a treatable but

incurable disease. They were requested to attend self-help meetings in

addition to their regularly scheduled sessions. The regularly scheduled

sessions consisted of both supportive and confrontive therapy, didactic

lectures, and videos on cocaine dependence, AIDS, the disease model

of addiction, and the self-help orientation. Patients were expected to

identify a sponsor from a local self-help group by week 12.

Counseling was delivered by master’s-level counselors experienced in

standard drug and alcohol counseling, and clinical supervision was

provided by a master’s-level person with extensive experience in

delivering and supervising this type of treatment.

To participate in the study, subjects had to be 18 years of age or older

and meet DSM III-R criteria for cocaine dependence. The groups

differed significantly on only two subject characteristics. Subjects in

the behavioral treatment reported ingesting more cocaine per week

(10.2 ± 8.6 g/week versus 3.7 ± 3.8 g/week) prior to entering treatment

and had a significantly greater proportion of intravenous cocaine users

(69 percent versus 17 percent) than the standard counseling group.

Acceptability of the behavioral treatment and drug abuse counseling to

patients was inferred from the number who failed to attend more than

one therapy session in the two groups. All who were offered the

behavioral treatment accepted it, while 12 of 15 (80 percent) accepted

102
12-step counseling. Treatment retention was significantly better in the

behavioral treatment than drug abuse counseling (p<0.05). Eleven of

the thirteen (85 percent) subjects in the behavioral treatment versus 5

of 12 (42 percent) in the drug and alcohol counseling group were

retained for 12 weeks of counseling. Subjects from the behavioral

treatment achieved significantly longer periods of continuous cocaine

abstinence than subjects in the 12-step counseling group (p<0.01)

(figure 1). For example, 78 percent of the subjects in the behavioral

group achieved 4 or more weeks of continuous cocaine abstinence

versus 25 percent of the subjects in the counseling group. No

members of the counseling group achieved more than 7 weeks of

continuous cocaine abstinence, while 46 percent of the subjects in the

FIGURE 1. Periods of continuous cocaine abstinence in patients

receiving behavioral treatment and drug and alcohol

counseling. The height of each bar represents the

percentage of patients (y-axis) achieving a duration of

documented cocaine abstinence greater than or equal to

the number of weeks indicated (x-axis).

SOURCE: Higgins et al. 1991

103
behavioral group achieved 8 or more weeks of continuous cocaine

abstinence, and 23 percent achieved 12 weeks.

Randomized Trial. This initial trial comparing the behavioral

treatment and standard drug and alcohol counseling was followed by a

randomized trial comparing the same two treatments (Higgins et al.

1993a). Thirty-eight patients were randomly assigned to the two

treatments (19 per group). Patient characteristics did not differ

significantly across the two treatment groups. Treatment duration was

6 months in both groups. The main differences from the initial trial

were that urine specimens were not collected on Saturdays, treatment

duration was increased from 3 to 6 months, and disulfiram therapy was

available to both treatment groups. Eight of the patients in the

behavioral treatment group received disulfiram therapy at some point

during the 24 weeks of treatment. Only one patient in the standard

counseling group received disulfiram therapy, which is consistent with

a common reluctance among traditionally trained drug abuse

counselors to recommend disulfiram therapy.

One (5 percent) patient in the behavioral treatment versus eight

(53 percent) in drug abuse counseling failed to attend more than one

session (p = 0.02). Significantly more patients in the behavioral

treatment than drug abuse counseling completed treatment (p<0.01).

For example, 84 percent and 58 percent of those in the behavioral

treatment completed 12 and 24 weeks of treatment, compared with 26

percent and 11 percent in drug abuse counseling. When cocaine

abstinence was analyzed as a function of consecutive treatment weeks,

significantly larger numbers of patients in the behavioral group were

abstinent during weeks 3-24 (p<0.05, figure 2, upper panel).

Importantly, the incentives in the behavioral treatment were decreased

in magnitude from the vouchers to lottery tickets at the end of week 12

without a precipitous decrease in cocaine abstinence (figure 2, upper

panel). Significant differences also were evident when continuous

cocaine abstinence was compared (p = 0.005). For example,

68 percent and 42 percent of patients in the behavioral treatment

achieved at least 8 and 16 weeks of documented continuous cocaine

abstinence versus 11 percent and 5 percent in drug abuse counseling

(figure 2, lower panel).

104
FIGURE 2. Upper panel: Percentage of patients (y-axis) in

behavioral treatment and drug abuse counseling in whom

cocaine abstinence was documented during consecutive

weeks of treatment (x-axis). Lower panel: Periods of

continuous cocaine abstinence in patients receiving

behavioral treatment and drug and alcohol counseling.

The height of each bar represents the percentage of

patients (y-axis) achieving a duration of documented

cocaine abstinence greater than or equal to the number of

weeks indicated (x-axis).

SOURCE: Higgins et al. 1993a

105
This trial replicated the results from the nonrandomized trial, extended

them to a longer treatment period, and demonstrated that treatment

gains were maintained after the voucher system was discontinued. The

consistency of the results observed across the two trials demonstrates

the reliability of the effects of this behavioral treatment and strongly

suggests that any outcome differences observed between this treatment

and standard drug abuse counseling are not attributable to inadvertent

differences in subject characteristics. It merits mention that the

difference between the two treatments in this trial in the number of

patients who received disulfiram therapy cannot account for the

outcome differences observed, as similar differences were observed in

the earlier trial in which only one patient in the behavioral treatment

group received disulfiram therapy. As is reported below, disulfiram

therapy is associated with clinical improvement in this population, but

it does not account for the large magnitude and reliable differences

observed between the behavioral treatment and drug and alcohol

counseling in these two trials. The relatively poor outcomes observed

with drug and alcohol counseling in these trials are comparable with

those reported previously in outpatient counseling for cocaine

dependence (e.g., Kang et al. 1991).

Randomized Trial Comparing the Behavioral Treatment With

Versus Without the Voucher System

It is not known at this time which components of this multicomponent

behavioral intervention are contributing significantly to the outcomes

observed. To begin to address that question, the authors currently are

conducting a trial in which patients are randomly assigned to two

groups. One treatment group receives the entire behavioral treatment

as described above, while the other group receives everything except

the voucher system. Described below are reported preliminary results

collected from 30 patients (15 per group) during the first 12 weeks of

treatment, which is when the voucher system is in effect (Higgins et al.

1993a). There were no significant differences in subject characteristics

between the treatment groups, and all subjects were 18 years of age or

older and met DSM III-R criteria for cocaine dependence as in the

prior trials.

The voucher system improved treatment retention, with 93 percent of

those who received vouchers completing 12 weeks of treatment versus

106
67 percent of those who did not receive them. Those who received the

vouchers also achieved greater levels of documented cocaine

abstinence (figure 3). For example, 67 percent of those who received

vouchers achieved 6 or more weeks of documented continuous cocaine

abstinence versus 40 percent of the group that did not receive

vouchers.

CONTINUOUS COCAINE ABSTINENCE

FIGURE 3. Periods of continuous cocaine abstinence in patients

receiving-behavioral treatment with and without the

voucher system. The height of each bar represents the

percentage of patients (y-axis) achieving a duration of

documented cocaine abstinence greater than or equal to

the number of weeks indicated (x-axis).

KEY: CRA+ = Community Reinforcement Approach with vouchers;

CRA- = Community Reinforcement Approach without

vouchers

107
Importantly, if the performance of the standard drug abuse counseling

group from the prior randomized trial is used as a historical control,

graded functions emerge. That is, levels of treatment retention and

cocaine abstinence are best with the complete treatment package,

intermediate with the behavioral treatment without vouchers, and

lowest with standard counseling (figure 4). When looked at in this

manner, it seems that the voucher system contributes significantly to

the efficacy of this behavioral treatment but other aspects of the

treatment package are also important. The studies described below

further support that position.

Retrospective Analysis of Predictors of Cocaine Abstinence

While the outcomes observed with the behavioral treatment package

are impressive, not everyone responds equally well. Thus, an

investigation of predictors of who succeeded in the treatment was

initiated. Towards that goal, a study was conducted using a stepwise

logistic regression to identify significant predictors of cocaine

abstinence during the initial 12 weeks of treatment in 52 patients who

received the behavioral treatment (Higgins et al., in press-b). Subjects

were classified as “successes” and “failures” based upon their longest

period of cocaine abstinence and the overall percentage of cocainenegative urine specimens submitted. Success was defined as having

achieved 9 or more weeks of continuous abstinence or greater than 92

percent overall cocaine abstinence during the initial 12 weeks of

treatment. Subjects not meeting either of those criteria were classified

as failures. The following variables were examined: age, gender,

years of education, employment status, weekly income, years of

regular cocaine use, average amount spent weekly on cocaine, average

number of grams of cocaine used weekly, longest period of

pretreatment cocaine abstinence since becoming a regular user, alcohol

dependence, marijuana dependence, Addiction Severity Index (ASI)

composite scores, and whether a subject had a significant other

participate in treatment.

Using these abstinence criteria, 28 subjects were classified as successes

and 24 as failures. The only significant predictor of success was

108
TREATMENT RETENTION

CONTINUOUS COCAINE ABSTINENCE

FIGURE 4. Upper panel: The percentage of patients who completed

12 weeks of treatment in the behavioral treatment with

and without the voucher system and a historical control

group that received drug and alcohol counseling. Lower

panel: Periods of continuous cocaine abstinence in

patients receiving the same treatments shown in the upper

panel. The height of each bar represents the percentage

of patients (y-axis) achieving a duration of documented

cocaine abstinence greater than or equal to the number of

weeks indicated (x-axis).

KEY: CRA+ = with Community Reinforcement Approach with

vouchers; CRA- = Community Reinforcement Approach

without vouchers; STD = Historical control group

109
having a significant other participate in treatment. Subjects who had a

significant other participate in treatment were estimated to be almost

20 times as likely to achieve criterion levels of abstinence as those

without a significant other participating in treatment.

Having a significant other participate in treatment was a robust

predictor of abstinence in this study. To the authors’ knowledge, this

is the first study on predictors of treatment outcome in cocaine

dependence to note a relationship between significant other

involvement in treatment and cocaine abstinence. Although it must be

documented in a prospective randomized trial, reciprocal relationship

counseling may contribute significantly to the positive treatment

outcomes observed with this multicomponent behavioral treatment.

Disulfiram Therapy in Patients Abusing Cocaine and Alcohol

As noted above, disulfiram therapy is a component of this behavioral

treatment approach and is offered to all patients who, in addition to

cocaine dependence, report evidence of concurrent alcohol dependence

or abuse. In this study, the authors attempted to assess for significant

clinical changes associated with that therapy (Higgins et al. 1993b).

To do so, results were examined from 16 patients who met DSM III-R

criteria for cocaine dependence and alcohol abuse/dependence.

Subjects were chosen on the basis of having 2 or more weeks on and

off disulfiram therapy, which provided an opportunity to assess for

associated benefits. Because patients often determined when disulfiram

therapy was terminated, causality for any changes observed could not

be determined.

The average durations on and off disulfiram therapy were 69.5 days ±

11.9 S.E.M. and 93.4 days ± 10.7. The off-disulfiram period preceded

the on period in 10 patients and followed it in 6 others. Patients

reported to the clinic two or three times weekly and ingested

disulfiram under staff supervision. Breath and urine specimens were

collected under staff observation during those visits. Take-home doses

of disulfiram were provided for the other days. Other than the

attempts to supervise ingestion, disulfiram therapy was provided using

standard procedures (Puller et al. 1986). Patients generally ingested a

single 250 mg/daily dose. Disulfiram therapy was associated with

110
significant decreases in measures of drinking and cocaine use

(figure 5).

Patients reported an average of 0.05 ± 0.02 drinking days weekly while

taking disulfiram versus 1.5 ± 0.4 off the medication (p = 0.001). The

average number of drinks per drinking occasion while taking

disulfiram was 4.7 ± 2.2 versus 10.9 ± 2.6 off the medication. The

frequency of cocaine use was already suppressed due to the efficacy of

the behavioral treatment patients were receiving. Nevertheless, the

percentage of cocaine positive specimens while taking disulfiram was

11 percent ± 3 versus 25 percent ± 6 off the medication (p = 0.01).

In summary, supervised disulfiram therapy was associated with

significant decreases in alcohol and cocaine use. Controlled trials will

be necessary to evaluate adequately the direct contribution of

disulfiram therapy to these outcomes. Considering the large proportion

of cocaine abusers who abuse alcohol, such trials merit serious

consideration. It appears that in that subset of patients who are also

alcohol abusers, including the disulfiram component may contribute

significantly to the positive outcomes observed with this behavioral

treatment package.

Contingency-Management Procedures in Patients Abusing

Cocaine and Marijuana

This study examined the efficacy of the voucher system for controlling

cocaine and marijuana use by multiple-drug abusers (Budney et al.

1991). Subjects were two males who received the behavioral treatment

described above. Both were cocaine dependent; S-l also met criteria

for marijuana dependence, while S-2 met criteria for marijuana abuse.

Both subjects achieved almost complete cocaine abstinence but

continued regular marijuana use during the 12 weeks in which

vouchers were available contingent on cocaine abstinence (figure 6,

cocaine-abstinence phase). In a subsequent phase, reinforcement

magnitude was reduced to $1 lottery tickets delivered contingent on

submission of cocaine-free urine specimens. Weekly l-hour behavior

therapy sessions were continued during this period, and urine

specimens were collected twice weekly (Monday and Thursday).

111
ALCOHOL USE

ON vs. OFF DISULFIRAM

COCAINE USE

ON vs. OFF DILSUFIRAM

FIGURE 5. Upper panels: Self-reported average number of alcoholic

drinks per week and self-reported average number of

drinks per drinking occasion. Lower panel: Average

percent cocaine-positive urinalysis results while on and

off disulfiram therapy. Brackets represent ± 1 S.E.M.

112
During this period, both subjects maintained the patterns of cocaine

abstinence and regular marijuana use exhibited in the initial phase

(figure 6, cocaine-maintenance phase). Next, these individuals were

given a 2-week notice that the reinforcement program conducted in the

initial phase would be available for another 12 weeks but that points

were now contingent on both cocaine and marijuana abstinence.

Delivery of the notice to the individual subjects was staggered across

time in the tradition of a multiple-baseline research design (Baer et al.

1968). Schedules of urine monitoring and therapy remained as in the

second phase. The overall value of vouchers that could be earned

during the 12 weeks of this third phase was the same as in the initial

phase. During this third phase, S-l and S-2 provided 96 percent (23 of

24) and 100 percent (24 of 24) negative benzoylecgonine and

cannabinoid urine specimens (figure 6, cocaine-marijuana-abstinence

phase). The temporal order of the change in urinalysis results across

the two subjects coincided with the staggered intervention times,

strongly suggesting that the changed contingencies controlled the

changes in marijuana use.

At followup visits scheduled at 1 and 5 months after treatment

termination, both subjects remained cocaine abstinent but had resumed

marijuana use. Interestingly, both subjects deemed cocaine use a

serious problem and requested treatment for it but did not deem

marijuana use a problem. The present results demonstrate that

abstinence from both substances can be achieved by arranging the

reinforcement contingencies appropriately, but treatment gains made

with the substance not deemed by patients as problematic may be

relatively transient.

DISCUSSION

This behavioral treatment is very acceptable to patients. The vast

majority (98 percent) of individuals who have been offered the

treatment have accepted. Treatment acceptability to dependent

individuals is important, especially because many of the individuals

treated thus far were intravenous users at risk for contracting and

spreading AIDS and other diseases (Chaisson et al. 1989). Current

pharmacotherapies often are rejected by 30 percent or more of those

offered treatment (e.g., Gawin et al. 1989; Weddington et al. 1991),

113
FIGURE 6. The cumulative number of negative cocaine and

marijuana urinalysis results obtained during three phases

of treatment are shown as a function of consecutive

urinalysis tests conducted throughout treatment. Cocaine

and marijuana are represented by closed and open

symbols, respectively.

SOURCE: Budney et al. 1991

114
and behavioral therapies with aversive contingencies are rejected by as

many as 50 percent of patients (Anker and Crowley 1982). Thus, this

treatment may be more acceptable to patients than alternative

pharmacological and psychological therapies.

The treatment is effective in retaining patients in treatment. Across the

trials conducted to date, more than 85 percent of patients have

completed 12 or more weeks of treatment. The same issues that

underscore the importance of treatment acceptability apply to treatment

retention. As long as the individual remains in treatment, opportunities

exist to facilitate behavior change. Longer stays in drug abuse

treatment are associated with improved outcomes (e.g., Anglin and

McGlothlin 1984), and once patients exit treatment, all opportunities to

influence any aspect of their characteristically high-risk behavioral

repertoires are lost.

The behavioral treatment is effective in establishing initial cocaine

abstinence, as this has now been replicated in several trials (Higgins et

al. 1991, 1993a). The obvious challenge is to address questions of

longer-term abstinence and the generality of these findings to other

clinics and populations. The 6-month randomized trial described

above was a first step towards addressing the challenge of longer term

abstinence, and the findings were encouraging (Higgins et al. 1993a).

Clinically significant periods of continuous cocaine abstinence were

engendered in the majority of patients, and, at the end of 3 months of

treatment, patients could be transitioned from the voucher system to

the lower magnitude lottery tickets without a precipitous drop in

cocaine abstinence levels. With regard to the issue of generality to

other settings, several clinics located in large urban areas plan to

examine the efficacy of either particular components of this treatment

or the entire package. Thus, information regarding the generality of

this treatment approach to other settings should be forthcoming.

This treatment can be adapted to address the high levels of alcohol and

marijuana abuse common among cocaine-dependent individuals.

Because the majority of cocaine-dependent persons also abuse these

other drugs, any effective treatment for cocaine dependence must be

able to address these other forms of drug abuse as well. The results

observed with disulfiram therapy suggest that addressing alcohol abuse

in this population is associated not only with significant decreases in

115
alcohol consumption but also with significant decreases in cocaine use

(Higgins et al. 1993b). Considering that almost all cocaine-dependent

individuals use alcohol and the majority do so in an abusive manner,

this could be a very important observation (Grant and Harford 1990).

Controlled trials examining the efficacy of disulfiram in the treatment

of cocaine dependence are needed.

The information provided above on marijuana use suggests that some

individuals can use regularly without it adversely affecting cocaine

abstinence. Marijuana use in those subjects is readily modifiable by

means of a direct contingency-management intervention, although such

changes appear to dissipate when the contingency is removed. More

information is needed on the influence of marijuana use on efforts to

achieve cocaine abstinence so that clinicians can make informed

decisions about how to address use of that substance during treatment

for cocaine dependence.

An important feature of this treatment approach is its direct ties to

basic research in behavioral pharmacology and behavior analysis. As

was noted above, this treatment is conceptualized and structured in

terms of the basic principles and concepts of those scientific

disciplines. Operating according to a common set of concepts and

principles in the basic research and clinical domains should support

effective communication between those settings and facilitate a

scientific approach to the treatment and prevention of drug

dependence.

The preliminary results of the trial comparing the behavioral treatment

with and without the voucher system indicate that including it

improves treatment retention and cocaine abstinence. Although the

costs of such a voucher system (maximum of $11-$12 per day across

3 months) may seem prohibitive at first blush, they pale, for example,

in comparison to those incurred with the typical 28-day inpatient

hospitalization for substance abuse or the costs incurred in caring for

an individual who has contracted AIDS (Holder and Blose 1991;

Drucker 1986). Additionally, it is important that the behavioral

processes involved in the treatment described in this chapter receive

attention, not just the nature of the incentives used. This intervention

illustrates the potential utility of frequent, contingent use of positive

reinforcement in the treatment of cocaine dependence. It is possible

116
that the nature of the reinforcers used could be quite varied (i.e., one

should not assume that vouchers redeemable for retail items are a

necessary feature). Also, if they are necessary, clinics may consider

creative and cost-effective strategies for providing them. For example,

nonprofit clinics may consider petitioning community retailers to

donate items to be used as incentives. Use of access to community

athletic facilities or other community resources is another possibility.

Results from the retrospective analysis of predictors of cocaine

abstinence in this behavioral treatment strongly suggest that social

reinforcers delivered systematically by significant others may play a

significant role in establishing cocaine abstinence (Higgins et al., in

press-b). Although those findings need to be documented in a

prospective, randomized trial, they illustrate the varied ways in which

differential reinforcement procedures can be applied in trying to

engender and maintain cocaine abstinence.

Overall, the findings reviewed in this report illustrate that systematic

application of basic behavioral concepts and principles can play an

important role in effective treatment for cocaine and other forms of

drug dependence.

NOTE

This chapter is based in part on the brief review published previously

(Higgins et al., in press-a).

REFERENCES

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict

treatment in California. In: Tims, F.M., and Ludford, J.P., eds. Drug

Abuse Treatment Evaluation: Strategies, Progress, and Prospects.

National Institute on Drug Abuse Research Monograph 51. DHHS

Pub. No. (ADM)84-1329. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1984. pp. 106-128.

117
Anker, A.A., and Crowley, T.J. Use of contingency contracts in

specialty clinics for cocaine abuse. In: Harris, L.S., ed. Problems of

Drug Dependence 1981. National Institute on Drug Abuse Research

Monograph 41, NTIS Pub. No. 82-190760. Washington, DC: Supt.

of Docs., U.S. Govt. Print. Off., 1982. pp. 452-459.

Azrin, N.H., and Besalel, V.A. Job Club Counselor’s Manual.

Baltimore: University Park Press, 1980.

Azrin, N.H.; Naster, B.J.; and Jones, R. Reciprocity counseling: A

rapid learning based procedure for marital counseling. Behav Res

Ther 11:364-382, 1973.

Baer, D.M.; Wolf, M.M.; and Risley, T.R. Some current dimensions of

applied behavior analysis. J Appl Behav Anal 1:91-97, 1968.

Bigelow, G.E.; Stitzer, M.L.; Griffiths, R.R.; and Liebson, I.A.

Contingency management approaches to drug self-administration

and drug abuse: Efficacy and limitations. Addict Behav 6:241-252,

1981.

Brady, J.V. Common mechanisms in substance abuse. In: Thompson,

T., and Johanson, C.E., eds. Behavioral Pharmacology of Human

Drug Dependence. National Institute on Drug Abuse Research

Monograph 37. DHHS Publ. No. (ADM)81-1137. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1981. pp. 11-20.

Budney, A.J.; Higgins, S.T.; Delaney, D.D.; Kent, L.; and Bickel,

W.K. Contingent reinforcement of abstinence with individuals

abusing cocaine and marijuana. J Appl Behav Anal 24:657-665,

1991.

Chaisson, R.E.; Bacchetti, P.; Osmond, D.; Brodie, B.; Sande, M.A.;

and Moss, A.R. Cocaine use and HIV infection in intravenous drug

users in San Francisco. JAMA 261:561-565, 1989.

Drucker, E. AIDS and addiction in New York City. Am J Drug

Alcohol Abuse 12:165-181, 1986.

Fuller, R.K.; Branchey, L.; Brightwell, D.R.; Derman R.M.; Emrick,

C.D.; Iber, F.L.; James, K.E.; Lacoursiere, R.B.; Lee, K.K.;

Lowenstam, I.; Maany, I.; Neiderhiser, D.; Necks, J.J.; and Shaw,

S. Disulfiram treatment of alcoholism: A Veterans Administration

cooperative study. JAMA 256: 1449-1455, 1986.

Gawin, F.H.; Kleber, H.D.; Byck, R.; Rounsaville, B.J.; Kosten, T.R.;

Jatlow, P.I.; and Morgan, C. Desipramine facilitation of initial

cocaine abstinence. Arch Gen Psychiatry 46:117-121, 1989.

Goldberg, S.R., and Stolerman, I.P. Behavioral Analysis of Drug

Dependence. Orlando, FL: Academic Press, 1986.

118
Grant, B.F., and Harford, T.C. Concurrent and simultaneous use of

alcohol with cocaine: Results of a national survey. Drug Alcohol

Depend 25:97-104, 1990.

Griffths, R.R.; Bigelow, G.E.; and Henningfield, J.E. Similarities in

animal and human drug taking behavior. In: Mello, N.K., ed.

Advances in Substance Absue: Behavioral and Biological Research.

Greenwich, CT: JAI Press, 1980.

Henningfield, J.E.; Lukas, S.E.; and Bigelow, G.E. Human studies of

drugs as reinforcers. In: Goldberg, S.R., and Stolerman, I.P., eds.

Behavioral Analysis of Drug Dependence. Orlando, FL: Academic

Press, 1986. pp. 69-113.

Higgins, S.T.; Budney, A.J.; and Bickel, W.K. Applying behavioral

concepts and principles to the treatment of cocaine dependence.

Drug Alcohol Depend, in press-a.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; and Badger, G.J.

Participation of significant others in outpatient behavioral treatment

predicts greater cocaine abstinence. Am J Drug Alcohol Abuse, in

press-b.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; and Foerg, F.

Disulfiram therapy in patients abusing cocaine and alcohol. Am J

Psychiatry 150:675-676, 1993b.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.;

and Badger, G. Achieving cocaine abstinence with a behavioral

approach. Am J Psychiatry 150:763-769, 1993a.

Higgins, S.T.; Delaney, D.D.; Budney, A.J.; Bickel, W.K.; Hughes,

J.R.; Foerg, F.; and Fenwick, J.W. A behavioral approach to

achieving initial cocaine abstinence. Am J Psychiatry

148:1218-1224, 1991.

Holder, H.D., and Blose, J.O. Typical patterns and cost of alcoholism

treatment across a variety of populations and providers. Alcoholism

(NY) 15:190-195, 1991.

Kang, S.-Y.; Kleinman, P.H.; Woody, G.E.; Millman, R.B.; Todd,

T.C.; Kemp, J.; and Lipton, D.S. Outcomes for cocaine abusers

after once-a-week psychosocial therapy. Am J Psychiatry

148:630-635, 1991.

Sisson, R.W., and Azrin, N.H. The community reinforcement approach.

In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism

Treatment Approaches: Effective Alternatives. New York: Pergamon

Press, 1989. pp. 242-258.

119
Stitzer, M.L.; Bigelow, G.E.; and Gross, J. Behavioral treatment of

drug abuse. In: Karsu, T.B., ed. American Psychiatric Association

Treatment Manual. Washington, DC: American Psychiatric

Association, 1989.

Weddington, W.W.; Brown, B.S.; Haertzen, C.A.; Hess, J.M.;

Mahaffey, J.R.; Kolar, A.F.; and Jaffe, J.H. Comparison of

amantadine and desipramine combined with psychotherapy for

treatment of cocaine dependence. Am J Drug Alcohol Abuse

17:137-152, 1991.

Young, A.M., and Herling, S. Drugs as reinforcers: Studies in

laboratory animals. In: Goldberg S.R., and Stolerman, I.P., eds.

Behavioral Analysis of Drug Dependence. Orlando, FL: Academic

Press, 1986. pp. 9-67.

ACKNOWLEDGMENTS

This research was supported by USPHS Treatment Research

Demonstration Grant R18 DA06113 and Training Grant T32 DA07242

from the National Institute on Drug Abuse. We acknowledge G.

Badger, M.S., for assistance with statistical analyses and W.K. Bickel,

Ph.D., and J.R. Hughes, M.D., for their scientific contributions to the

research described in this chapter.

AUTHORS

Stephen T. Higgins, Ph.D.

Associate Professor of Psychiatry and Psychology

Department of Psychiatry and Psychology

and

Human Behavioral Pharmacology Laboratory

Alan J. Budney, Ph.D.

Postdoctoral Fellow

Department of Psychiatry

and

Human Behavioral Pharmacology Laboratory

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University of Vermont

38 Fletcher Place, Ira Allen School

Burlington, VT 05401

121

Cognitive Therapy of Substance

Abuse: Theoretical Rationale

Fred D. Wright, Aaron T. Beck, Cory F. Newman, and

Bruce S. Liese

“The practical effect of a belief is the real test of its soundness.”

James A. Froude

INTRODUCTION

Millions of Americans have substance abuse problems. In fact, at least

1 in 10 adult Americans has a serious alcohol problem (Institute of

Medicine 1987). At least one in four adult Americans is addicted to

nicotine (Centers for Disease Control 1991a ). Approximately 1 in 35

Americans over the age of 12 is an illicit drug user (Institute of

Medicine 1990a). Substance abuse results in profound social, medical,

and psychological problems. For example, it has been estimated that

approximately 434,000 people in this country die each year as a result

of cigarette smoking (Centers for Disease Control 1991b). Many

thousands also die as a result of alcoholism (Institute of Medicine

1987, 1990b) and illicit drug abuse (Institute of Medicine 1990a ).

There are many different ways of conceptualizing substance abuse

(Beck et al. 1993; Blane and Leonard 1987; Brickman et al. 1982; Cox

1990). Although the disease model and 12-step programs continue to

dominate the treatment literature and practice, several authors have

developed social learning, or cognitive-behavioral, approaches for

understanding and treating substance abuse disorders (e.g., Abrams and

Niaura 1987; Annis 1986; Marlatt 1978, 1982, 1985; Marlatt and

Gordon 1980, 1985). In fact, efforts even have included rational

emotive approaches to treating substance abuse (e.g., Ellis et al. 1988;

Trimpey 1989). This chapter presents the theoretical rationale for the

cognitive therapy of substance abuse based on work at the Center for

Cognitive Therapy, University of Pennsylvania.

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The Cognitive Therapy Model

Cognitive therapy is an active, collaborative, focused form of

psychotherapy developed from the findings that psychological

disturbances frequently involve habitual errors in thinking (Beck 1976;

Beck et al. 1979). The underlying theoretical rationale stipulates that

the way an individual feels and behaves is largely determined by the

way he or she construes his or her experiences. Further, the model

stipulates that psychological disorders are characterized by

dysfunctional thinking derived from dysfunctional beliefs. Initial

improvement results from modification of the dysfunctional thinking

and durable improvement from modification of dysfunctional beliefs.

The cognitive model of substance abuse asserts that certain individuals

have developed a cognitive vulnerability to drug abuse. Under

particular circumstances, specific beliefs are activated that increase the

likelihood of substance use (Beck et al. 1990a, 1992). Idiosyncratic

beliefs such as, “I cannot socialize without getting high,” are activated

in certain provocative situations, leading to increased risk of

succumbing to drug use.

Definition of Beliefs

Beliefs are relatively stable, enduring cognitive processes that, once

formed, are not easily modified by experience. Depressed patients

tend to have global negative views about themselves, the world, and

the future, which contributes to their feelings of despair, guilt, and

sadness (Beck et al. 1979). Similarly, anxious patients have specific

negative beliefs about some future threat, which contributes to

avoidance, anxiety, and, at times, panic attacks (Beck and Emery

1985). Without cognitive intervention, these pernicious beliefs tend to

endure in spite of objective evidence that there is hope or that the

perceived threat is minimal.

There are three major categories of dysfunctional beliefs associated

with the patient’s acute decision to engage in substance abuse:

1. Anticipatory,

2. Relief-oriented, and

3. Facilitative or permissive.

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Anticipatory beliefs usually involve some expectation of drug use, such

as, “I feel like a superman when I use.” Relief-oriented beliefs are

those that assume that using drugs will remove some uncomfortable

state: “The urges and cravings will not go away unless I use.”

Facilitative or permissive beliefs are those that consider drug use

acceptable even in spite of obvious potential consequences: “I deserve

it. I am a hard worker. There is nothing wrong with taking risks.”

The cognitive therapy model of substance abuse states that drug-using

beliefs and desires typically are activated in specific, common, often

predictable, high-risk circumstances. These circumstances can be

external or internal. Examples of external circumstances are seeing

drug paraphernalia or being at a party where cocaine or other drugs are

being used. Internal circumstances include uncomfortable emotional

states such as depression, anxiety, or boredom.

Numerous circumstances can trigger drug-related beliefs and,

consequently, drug use. It should be noted that the circumstances

previously mentioned do not directly cause drug use, though they may

seem to give rise to spontaneous use. The authors have observed a

sequence of events that occurs between the external/internal

circumstances and the actual drug use. The sequence of conditions is

as follows (see figure 1): the high-risk external/internal circumstance

is followed by the activation of a basic drug-related belief, which in

turn leads to associated automatic thoughts and further to

craving/urges. This in turn leads to the activation of facilitating beliefs

about drug use, which directs attention to instrumental strategies for

obtaining the drugs, which in turn leads to use. At this point, drug use

can serve as an additional external/intemal circumstance that triggers

other drug-related beliefs (e.g., “Since I have broken my abstinence, I

might as well go on a binge”), resulting in a vicious cycle (Beck et al.

1990a, 1992).

This series of conditions is illustrated in the following case. Mr. C. is

a 34-year-old drug abuser who completed a 28-day residential

treatment program. The following is an example of his first lapse.

The situation occurred when Mr. C. went to a bar (external) in order to

socialize because he felt extremely bored (internal). This, in turn,

activated a common drug-related (relief-oriented) belief: “I cannot

stand the boredom.” In turn, this condition led to the associated

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FIGURE 1. Cognitive model of substance abuse
automatic thought, “Go for it.” Instantly, extremely strong cravings

started, as he began to have images of the last time that he used. This,

in turn, activated another belief, “Urges and cravings make me use,”

and the facilitating belief, “Everybody in this town uses, so why not

me?” His instrumental strategy was to look around for someone in the

bar who might have some cocaine. Like a heat-seeking missile, all of

his attention was focused on hitting the target-getting cocaine. He

found some cocaine, used, and later felt guilty and hopeless, which

started the vicious cycle anew.

Case Conceptualization

There are four main components to the cognitive conceptualization of

the substance abuser:

1. Relevant childhood data,

2. Dysfunctional core beliefs,

3. Conditional assumptions, and

4. Compensatory strategies.

With regard to relevant childhood data, therapists try to ascertain the

early childhood experiences that contributed to the development and

maintenance of general dysfunctional core beliefs. These core beliefs

are the most central beliefs about how patients view themselves,

generally falling into two categories: believing that one is unlovable

or incapable. Conditional assumptions are implicit rules that patients

attempt to follow in order to thrive or avoid harm. They can be in the

form of a positive assumption, such as “If I gain control, then I will

feel effective,” or a negative counterpart: “If I do not do things

perfectly, then I am inferior.” Compensatory strategies are those

behaviors that help patients to cope (albeit temporarily and

ineffectively) with the core belief (e.g., avoiding tasks that they feel

they cannot do perfectly or using drugs that make them feel effective

and confident).

The case of Mr. C. illustrates these concepts. Mr. C. grew up in a

very unpredictable family. His father was a heavy drinker who often

acted impulsively and was emotionally abusive. He often would

humiliate Mr. C. in public, making comments about how stupid he was

and jokingly saying his son was adopted. The two core beliefs that the

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authors hypothesize developed as a result of these early childhood

experiences were, “I am inadequate and powerless” and, “I am

unwanted and undesirable.” Mr. C. developed a series of conditional

assumptions that stemmed from these core beliefs, including:

“If I am in control, then I will feel adequate.”

“If I do things perfectly, then people will like me.”

“If people show their emotions, then they are out of control, and

they will be rejected by others.”

In order to cope with his core beliefs, Mr. C. developed certain

compensatory strategies, one being to avoid showing others how he

really felt. That is, if he realized that he was going into a situation in

which he might become extremely anxious, his tendency was to avoid

the situation. He also developed an all-or-none style of handling tasks.

If he could not do what he considered perfect work, he tended to

procrastinate or avoid it altogether. Another compensatory strategy

was to drink and use cocaine. When using cocaine and alcohol, Mr.

C. tended to feel more powerful and more popular with others. He felt

more in control when using and believed that everything was going

perfectly and that people would like him.

Modifying Beliefs in Therapy

An important goal of cognitive therapy of substance abuse is to

identify and modify drug-related dysfunctional beliefs, replacing them

with more adaptive, functional beliefs. At the very least, the therapist

attempts to teach the patient to build functional beliefs that become

more salient than the drug-related beliefs. The ideal result is that the

patient will abstain from drug use.

In order to modify drug-related beliefs, the cognitive therapist must

have an accurate understanding of the role of such beliefs in the

patient’s life. Thus, a careful assessment of beliefs must be undertaken

for each patient. In the assessment, the therapist collects data about

the patient’s beliefs using two vehicles: therapist-patient interactions

during psychotherapy sessions and belief questionnaires.

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During the therapy session, some basic tasks are important for the

therapist to collect raw data and maintain a collaborative relationship

with the patient. The most important of these tasks is the therapist’s

use of open-ended questions and probing. This strategy facilitates an

examination of the structure and content of the patient’s beliefs. Some

examples of open-ended questions are the following: “What are your

thoughts about that?” “How do you explain your reactions?” “How

do you interpret what happened?” “What does that mean to you?”

As the patient responds to these questions, the therapist reflects what

the patient has said, with particular emphasis on beliefs expressed by

the patient. At various points in the interview, the therapist provides a

summary of what has been discussed, again with strong emphasis

placed on the patient’s beliefs. This technique is illustrated in the

following example. Mr. C. reported that during the week he was

feeling extremely angry and anxious. The therapist then asked him to

describe the specific situation. He reported that while at a party he

saw other people using cocaine, and he started having urges to use

again. The therapist then asked, “What thoughts were going through

your mind then?” Mr. C. recalled, “They can use and I cannot. I will

never be able to use again.” The therapist said, “Let us assume for the

moment that these thoughts are accurate. What about them is

important? What is the meaning to you?” Mr. C. replied, “It means

that I will always be this way” (angry and anxious). The therapist

once again asked, “And what is the meaning of that to you? How

does that impact on you?” Mr. C. replied, “I will always have these

urges and feel anxious.” The therapist asked, “And how does that

impact on you?” Mr. C. replied, “It makes me feel helpless.” Two

important beliefs were uncovered in this brief interchange: “I will

always have these urges and feel anxious,” and, “I feel helpless about

this.”

In addition to the interview process, several questionnaires are

available to collect data about an individual’s beliefs. Some are

designated to evaluate more general beliefs, such as the Dysfunctional

Attitude Scale (Weissman and Beck 1978), while others are designed

specifically to assess drug-related beliefs. This chapter will focus on

those scales that are used specifically to assess the drug-related beliefs.

The following are scales that can be used in making this assessment:

the Beliefs About Substance Use (figure 2), the Craving Belief

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Listed below are some common beliefs about drug use. Please read each statement and rate how much you

agree or disagree with each one.

1. Life without using is boring.

2. Using is the only way to increase my creativity and productivity.

3. I cannot function without it.

4. This is the only way to cope with pain in my life.

5. I am not ready to stop using.

FIGURE 2. Beliefs about substance abuse: Sample of Items
Questionnaire-CQ (figure 3), and the Relapse Prediction Scale

(figure 4). These instruments are given to the patient at the beginning

of therapy to provide baseline information. They also are completed at

subsequent visits to assess changes that may occur as therapy

progresses. During the therapy process, these questionnaires help

therapists to understand the patient’s beliefs as they relate to target

areas for intervention. For example, during his initial visit, Mr. C.

endorsed strongly the following statements on the Beliefs About

Substance Use Questionnaire:

“Life without using is boring.”

“My life will not get any better even if I stop using.”

“The urges and cravings will not go away unless I use drugs.”

These responses give the therapist important information regarding

target areas for intervention. They allow the therapist to quickly

conceptualize some of the patient’s problems and to target certain

beliefs that will need to be modified.

On the Craving Belief Questionnaire, Mr. C. endorsed the following

statements:

“Since I will have cravings the rest of my life, I might as well go

ahead and use cocaine.”

“If the craving gets too intense, cocaine is the only way to cope

with the feelings.”

“The craving makes me use cocaine.”

Early in therapy, the therapist has been able to identify important drugrelated beliefs that are maintaining the patient’s drug use or making the

patient vulnerable to a lapse or relapse.

On the Relapse Prediction Scale, Mr. C. endorsed items that clearly

identify certain high-risk circumstances for him. For example, he

stated that the likelihood of using again would be strong in the

following circumstances:

“I am having a drink.”

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1. The craving is totally out of my control.

2. The craving is a physical reaction, therefore, I cannot do anything about it.

3. If I do not stop the cravings they will get worse.

4. Craving can drive you crazy.

5. The craving makes me use cocaine.

FIGURE 3. Craving Belief Questionnaire (CQ): Sample of Ideas
As you know, there are many situations that can trigger an urge to use cocaine or crack. This scale has two

parts: (1) to determine how strong you think the urges will be in certain situations and (2) what is the

likelihood of your using in these situations.

PREDICTION

Strength Likelihood

o f of

Urges Using

1. I am in a place where I used cocaine or crack before.

2. Around people with whom I have previously used cocaine or crack.

3. I just got paid.

4. I see co-workers using.

5. I am leaving work.

FIGURE 4. Relapse Predication Scale: Sample of Items
“I am around people with whom I previously used cocaine and

crack.”

“I feel bored.”

As can be seen from this list of situations, the Relapse Prediction Scale

allows the therapist to target certain vulnerable circumstances very

quickly. This information allows the therapist to suggest prompt

coping interventions early in treatment to reduce the likelihood of a

lapse or relapse.

Orienting the Drug-Abusing Patient to the Cognitive Therapy

Model

Most drug abusers have an external view of their problem. They may

believe, for example, that, “Under my current circumstance, I have no

control whatsoever,” or, “I just need to submit myself to the doctors

and they will cure me.” Thus, it is important that patients be oriented

to the cognitive therapy model in the initial stages of therapy.

Orienting the patients involves modifying their beliefs about control

from an externalized orientation (e.g., “Control is beyond me”) to a

more internalized control orientation such as, “I can expect some

control over myself and my drug use.” As part of the process of

orienting the patient, key terms are defined, including drug-related

beliefs, adaptive beliefs, automatic thoughts, external/internal

circumstances, lapse, and relapse.

The interrelationship between these phenomena is explained with

emphasis on the role of beliefs in drug use. The actual process of

orienting the patient to the cognitive therapy model varies from person

to person depending on each individual’s aptitude for self-examination.

For example, a psychologically minded individual might easily accept

the idea that thoughts and feelings are important and worthy of

examination. With such an individual, it might be relatively easy to

explain the cognitive therapy model using diagrams, drawings, and

analogies. On the other hand, some patients will be more concrete in

their cognitive style, requiring repeated use of simple examples.

Regardless of the process used, the primary goal of orienting the

patient to the cognitive therapy model is to begin modifying

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dysfunctional beliefs, with particular importance being placed on

dysfunctional drug-related beliefs.

An essential part of this orientation involves helping the patient to

understand how beliefs can develop and change over time. The

development of various types of beliefs is illustrated in the following

case. Mr. C. had the initial belief that he could not become addicted

to cocaine. He felt that he had complete control and that he could be a

recreational user. Initially, he used cocaine only in social situations.

Later, he developed a belief that he could work better using cocaine

and that the drug gave him more energy and made him more creative.

This, in turn, led to the use of cocaine prior to going to work and

especially when he was under pressure to meet deadlines. It is

interesting to note that Mr. C. had the illusion that he was more

productive at work when using cocaine, when, in fact, the objective

data indicated that he became less productive because of missed days

from work following weekend binges. Later, when he tried to stop

using and he began to experience stronger urges and cravings, Mr. C.'s

beliefs became focused on the cravings themselves. Some of these

beliefs were: “I cannot stand the cravings.” “The feelings will not go

away.” “The cravings make me use.” Later, when his life appeared to

be falling apart, he was in debt, and his wife was considering leaving

him, he developed the belief that his problems would still be just as

awful even if he stopped using cocaine.

As shown in the above illustration, Mr. C. had a series of beliefs that

developed over time that lead to his feeling hopeless about his

situation and facilitated his increased use of cocaine.

Examining and Testing Beliefs

Generally, beliefs develop over an extended period of time. As a

result, they become overlearned and extremely resistant to change

(Beck et al. 1990b; Young 1990). The drug abuser collects data

supporting beliefs such as “Drugs are fun and very exciting,”

“Cocaine greatly enhances sex and many other activities,” “Nothing is

quite like using cocaine,” and so forth. Many substance abusers have

spent years rejecting more functional beliefs such as “Drugs are

harmful.” Though many patients have tried to quit using drugs, their

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difficulty in doing so provides them with apparent validation for

beliefs such as “I am not in control of my problem” or “I am helpless.”

Given the resistant nature of drug-related beliefs, the process of

modifying them requires much diligent therapeutic work. After the

therapist has assessed the patient’s beliefs and oriented the patient to

the cognitive therapy model, an examination and testing of beliefs

should begin. Examining drug-related beliefs involves asking patients

probing questions that lead to closer scrutiny of these beliefs. This

process is known as the Socratic method, or guided discovery. The

following are some examples of questions appropriate for this process:

“What is your evidence for that belief?”

“How do you know the belief is true?”

“Where did you learn that?”

“How strongly do you believe that?”

“How likely is it that your belief is true?”

The primary goal of Socratic questioning is to heighten the patient’s

awareness of his or her functioning. As the patient considers the

therapist’s questions, drug-related beliefs should begin to “loosen;” that

is, he or she should begin to understand that these beliefs are biased

and there is a possibility that they are incorrect and self-defeating.

Mr. C. had developed the belief that urges and cravings made him use.

However, through questioning, the therapist was able to help him

examine this belief. One of the key questions in helping Mr. C. to

modify this belief was, “What is the evidence against the idea that

cravings make you use?” Upon reflection, Mr. C. realized that he did

not always use when he had urges and cravings. Nevertheless, he had

the illusion that every time he had an urge he gave into it. The

therapist instructed the patient to list recollections of times when he

had had strong urges and cravings to use cocaine but in fact did not

use. Reviewing this evidence helped to undermine Mr. C.'s very

strong belief that the urges and cravings made him use.

Development of Adaptive Beliefs

The therapist’s use of the Socratic method stimulates patients to

examine their drug-related beliefs, to modify them, and ultimately to

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replace them with more adaptive beliefs. For example, Mr. C. had the

belief that “There is only one way for me to have fun–to use drugs.”

First, the therapist asked him to list those activities that he enjoyed

before getting hooked on drugs. Mr. C. listed playing tennis, biking,

and going out to dinner with his wife, among others. The therapist

then asked Mr. C., “On a scale of 1 to 10, how much pleasure would

you get out of playing tennis now?” He replied, “Probably a 2.” The

therapist then asked Mr. C., “For homework, would you go play a

game of tennis and then rate on a 1-to-10 scale how much you enjoyed

it?” He agreed to do it. At the next therapy session, Mr. C. reported

that he did the homework and, to his surprise, he actually scored a 9,

which would indicate that he had had a good time.

This experiment helped to chip away at Mr. C.'s belief that “There is

only one way for me to have fun–to use drugs.” Mr. C. experimented

with other pleasurable activities, and eventually the aforementioned

dysfunctional belief became very weak. A new belief began to

emerge: “Besides doing drugs, there are many different things that I

enjoy.”

Another strategy for examining and testing drug-related beliefs and

developing adaptive beliefs is the use of the daily thought record

(DTR). The DTR is a structured form for listing and modifying

distorted thoughts. Specifically, the DTR has four columns containing

the following categories: situation, emotion(s), automatic thought(s),

and rational response. An example of a completed DTR appears in

figure 5.

For example, when patients experience urges or cravings, they write in

the situation column the triggering event. In the next column, they list

the feeling they are having. The automatic thoughts section is where

they write spontaneous negative thoughts and images associated with

how they are feeling. Alternative adaptive responses are written in the

rational response section.

This is illustrated by Mr. C.'s DTR (see figure 5). Under the column

entitled “situation,” Mr. C. described how he was sitting at home, he

recently had had an accident, his hand was broken, and he had plenty

of money in his pocket. Under “emotions” he wrote, “Bored.” Under

the “automatic thoughts” column, he had listed the following: “There

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DAILY THOUGHT RECORD (DTR)

SITUATION

Sitting at home; hand broken due to

recent accident; plenty of money in

my pocket.

EMOTION(S)

Bored

AUTOMATIC THOUGHT(S)

There is nothing to do. I cannot

stand the boredom. Therapy is not

doing me any good. I need a hit

to cool down.

RATlONAL RESPONSE

I have tolerated boredom in the past,

the same way I have tolerated other

feelings. Them are plenty of things

to do such as going to an AA

meeting.

FIGURE 5. Daily Thought Record (DTR)
is nothing to do,” “I cannot stand the boredom,” “Therapy is not doing

me any good.” and “I need a hit to cool down.” The therapist taught

Mr. C. to examine these automatic thoughts by asking himself the

following questions:

“What is the evidence for and against my automatic thoughts?”

“What are some other ways to look at this situation?”

“What are the realistic consequences?”

“What are the disadvantages of my continuing to say this to

myself?”

“What constructive action can I take?”

Mr. C. began by examining the thought “There is nothing to do” by

asking himself, “What is the evidence that there is nothing to do?” He

responded by saying, “There is no evidence that there is nothing to do.

Actually, there are plenty of things I can do; for example, I can go to

an Alcoholics Anonymous (AA) meeting or just get out of the house

and take a walk.”

Next he asked himself, “Is there another way of looking at this? Do I

really mean that there is nothing to do?” His response to this was,

“No, it is not true that there is nothing to do, but experiencing pain

and boredom makes it difficult for me to see other things that I might

be able to do.”

He then asked himseIf, “What are the realistic consequences if it is true

that there is nothing to do?” He responded, “Well, if it is true that

there is nothing to do, then the consequences are that I feel bored and,

although I do not like being bored, it is not the end of the world. The

consequences are that I will feel bored, but eventually it will go away.”

Mr. C.'s fourth question was, “What are the disadvantages of my

continuing to say this to myself?” He responded, “The disadvantage is

that I will feel helpless, which in turn will lead to the desire for

cocaine.” By examining these thoughts, he was able to produce

adaptive rational responses, such as “I have tolerated boredom in the

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past in the same way that I have tolerated other feelings. There are

plenty of things to do, such as going to an AA meeting.” These

responses represented Mr. C.'s early development of new, more

adaptive beliefs.

The final question (“What constructive action can I take?”) led Mr. C.

to consider what he could do to feel better without resorting to drugs.

He decided that he would begin to make a schedule for himself in

preparation for a return to work following the healing of his hand.

This activity made Mr. C. focus on his abilities and goals, not his

helplessness, and his concomitant drug urges diminished. Later, the

therapist was able to help Mr. C. examine the remaining automatic

thoughts and to come up with adaptive responses to those as well.

Another strategy for developing adaptive beliefs is the

advantage/disadvantage analysis. People use drugs partly because they

view the advantages of doing so as outweighing the disadvantages.

Thus, the purpose of the advantage/disadvantage analysis is to direct

the patient’s attention to the disadvantages of using cocaine and the

advantages of abstaining. The patient is taught to construct a 2x2

matrix where the advantages and disadvantages of using and not using

are listed and explored (figure 6).

Mr. C. listed the following advantages for using cocaine:

“I feel like a superman.”

“It takes away my shyness and insecurity.”

“I feel like king of the mountain.”

Under the disadvantages for using cocaine, he listed the following:

“I feel paranoid.”

“I have a terrible relationship with my wife.”

“I feel physically bad.”

Similar work was done to generate lists of advantages and

disadvantages for not using. The result was that Mr. C. learned that

there were compelling reasons to remain abstinent and that his reasons

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ADVANTAGE/DISADVANTAGE ANALYSIS

Advantages for Using: Disadvantages for Using:

1. “I feel like a superman.” 1. “I feel paranoid.”

2. “I takes away my shyness and insecurity.” 2. “I have a terrible relationship with my wife.”

3. “I fell like king of the mountain.” 3. “I feel physically bad.”

Advantages for Not Using: Disadvantages for Not Using:

1. “I save money.” 1. “I will be lonely.”

2. “I do not have to lie to my family.” 2. “I will not do as well sexually.”

3. “I will feel physically great.” 3. “I will lose friends.”

FIGURE 6. Advantage/disadvantage analysis
for using were based on falsehoods, rationalizations, and a

preoccupation with an immediate sense of power.

Practice In Activating Adaptive Beliefs

Upon completion of some of the above exercises, such as the DTR and

the advantage/disadvantage analysis, the patient is much more attentive

to the disadvantages of using drugs. Furthermore, the patient is better

able to successfully develop beliefs for resisting future drug use.

However, the patient frequently has trouble accessing these beliefs

when faced with the temptation. Hence, special attention must be paid

to the deliberate activation of adaptive beliefs as part of therapy.

There are several methods which serve this purpose. One method

involves the use of flashcards.

After the patient has formulated an adaptive belief, flashcards can be

used to reinforce and activate the newly developed belief. For

example, upon completing the advantage/disadvantage analysis, the

patient writes the advantages for not using on one or more 3"x5" index

cards. In the case of Mr. C., he wrote, “I feel more secure and less

paranoid when I do not use. I get along much better with my wife

when I do not use. I feel physically great in the long run when I do

not use.” He then read and repeated this card whenever he felt an urge

to use, which focused his attention on the importance of abstinence.

Homework

Homework involves applying the skills learned in the therapy session

to everyday life. Thus, homework is a vital extension of therapy

(Persons et al. 1988; Primakoff et al. 1986). As a result of repeated

use of homework in cognitive therapy, patients learn to use probing

questions spontaneously in their lives, such as “What evidence do I

have for this belief?” or “How else can I look at the situation?” or

“What are the consequences of my beliefs?” Homework is an

opportunity to practice applying adaptive beliefs in the real world

(Newman and Haaga, in press). Patients practice activating adaptive

beliefs in the face of tempting high-risk stimuli, since they inevitably

will be confronted with such stimuli in life outside of therapy.

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Homework also may involve testing drug-related beliefs to re-evaluate

their validity, such as the belief that the only way to have fun is to use

drugs. In the case of Mr. C., this belief was re-evaluated by getting

him to try alternative, nondrug, pleasure-seeking activities.

Homework is assigned at the end of each session and is reviewed at

the beginning of each following session. Initially, homework is quite

structured. For example, many new patients are instructed to complete

DTRs on a daily basis. Later, however, homework can be less formal

and more creative as the patient demonstrates skill in applying adaptive

patterns of thinking and action.

SUMMARY

In this chapter, the authors assert that drug-related beliefs are an

important factor in drug abuse and its treatment. Three types of acute

drug-related beliefs have been described that contribute to urges,

cravings, and ultimate use of drugs: anticipatory beliefs, relief-oriented

beliefs, and permissive beliefs, and various ways have been described

to assess more general, long-term beliefs pertinent to drug use. The

role of the cognitive therapist is to assess, examine, and test these

beliefs with the patient in order to ultimately develop more adaptive

beliefs. The active application of skills and homework that tap into

the patient’s adaptive beliefs helps the patient to become and remain

drug-free.

REFERENCES

Abrams, D.B., and Niaura, R.S. Social learning theory. In: Blane, H.T.,

and Leonard, K.E., eds. Psychological Theories of Drinking and

Alcoholism. New York: Guilford Press, 1987. pp. 131-178.

Annis, H.M. A relapse prevention model for treatment of alcoholics.

In: Miller, W.R., and Heather, N., eds. Treating Addictive

Behaviors: Process of Change. New York: Plenum Press, 1986.

Beck, A.T. Cognitive Therapy and the Emotional Disorders. New

York: International Universities Press, 1976.

143
Beck, A.T., and Emery, G. (with Greenberg, R.L.). Anxiety Disorders

and Phobias: A Cognitive Perspective. New York: Basic Books,

1985.

Beck, A.T.; Freeman, A.; Pretzer, J.; Davis, D.D.; Fleming, B.;

Ottawani, R.; Beck, J.; Simon, K.M.; Pedesky, C.; and Meyer, J.

Cognitive Therapy of Personality Disorders. New York: Guilford

Press, 1990b.

Beck, A.T.; Rush, A.J.; Shaw, B.F.; and Emery, G. Cognitive Therapy

of Depression. New York: Guilford Press, 1979.

Beck, A.T.; Wright, F.D.; and Newman, C.F. Cognitive Therapy of

Cocaine Abuse. Philadelphia, PA: Center for Cognitive Therapy,

1990a.

Beck, A.T.; Wright, F.D.; and Newman, C.F. Cocaine abuse. In:

Freeman, A., and Dattilio, F., eds. Comprehensive Casebook of

Cognitive Therapy. New York: Plenum Press, 1992.

Beck, A.T.; Wright, F.W.; Newman, C.F.; and Liese, B. Cognitive

Therapy of Substance Abuse. New York: Guilford Press, 1993.

Blane, H.T., and Leonard, K.E. Psychological Theories of Drinking

and Alcoholism. New York: Guilford Press, 1987.

Brickman, P.; Rabinowitz, V.C.; Karuza, J.; Coates, D.; Cohn, E.; and

Kidder, L. Models of helping and coping. Am Psychol 37:368-384,

1982.

Centers for Disease Control. Cigarette smoking among adults: United

States, 1988. Morbidity and Mortality Weekly Report 40:757-765,

1991a.

Centers for Disease Control. Smoking-attributable mortality and years

of potential life lost: United States, 1988. Morbidity and Mortality

Weekly Report 40:62-71, 1991b.

Cox, W.M., ed. Why People Drink. New York: Gardner Press, 1990.

Ellis, A.; McInerney, J.F.; DiGiuseppe, R.; and Yeager, R.J. RationalEmotive Therapy With Alcoholics and Substance Abusers. New

York: Pergamon Press, 1988.

Institute of Medicine. Causes and Consequences of Alcohol Problems.

Washington, DC: National Academy Press, 1987.

Institute of Medicine. Treating Drug Problems. Vol. 1. Washington,

DC: National Academy Press, 1990a.

Institute of Medicine. Broadening the Base of Treatment for Alcohol

Problems. Washington, DC: National Academy Press, 1990b.

144
Marlatt, G.A. Craving for alcohol, loss of control, and relapse: A

cognitive-behavioral analysis. In: Nathan, P.E.; Marlatt, G.A.; and

Lobert, T., eds. Alcoholism: New Directions in Behavioral Research

and Treatment. New York: Plenum Press, 1978.

Marlatt, G.A. Relapse prevention: A self-control program for the

treatment of addictive behaviors. In: Stuart, R.B., ed. Adherence,

Compliance, and Generalization in Behavioral Medicine. New

York: Brunner/Mazel, 1982.

Marlatt, G.A. Cognitive factors in the relapse process. In: Marlatt,

G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance

Strategies in the Treatment of Addictive Behaviors. New York:

Guilford Press, 1985. pp. 128-200.

Marlatt, G.A., and Gordon, J.R. Determinants of relapse: Implications

for the maintenance of behavior change. In: Davidson, P.O., and

Davidson, S.M., eds. Behavioral Medicine: Changing Health

Lifestyles. New York: Brunner/Mazel, 1980.

Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance

Strategies in the Treatment of Addictive Behaviors. New York:

Guilford Press, 1985.

Newman, C.F., and Haaga, D.A.F. Cognitive skills training. In:

O’Donohue, W., and Krasner, L., eds. Handbook of Skills Training.

Needham Heights, MA: Allyn and Bacon, in press.

Persons, J.B.; Bums, D.D.; and Perloff, J.M. Predictors of drop-out and

outcome in cognitive therapy for depression in a private practice

setting. Cogn Ther Res 12:557-575, 1988.

Primakoff, L.; Epstein, N.; and Covi, L. Homework compliance: An

uncontrolled variable in cognitive therapy outcome research. Behav

Ther 17:433-446, 1986.

Trimpey, J. The Small Book. Lotus, CA: Lotus Press, 1989.

Weissman, A.N., and Beck, A.T. “Development and Validation of the

Dysfunctional Attitudes Scale: A Preliminary Investigation.” Paper

presented at the Annual Meeting of the American Educational

Research Association, Toronto, Canada, 1978.

Young, J.E. Cognitive Therapy for Personality Disorders: A SchemaFocused Approach. Sarasota, FL: Professional Resource Exchange,

1990.

145
AUTHORS

Fred D. Wright, Ed.D.

Assistant Professor of Counseling Psychology in Psychiatry

University of Pennsylvania School of Medicine

and

Director of Education

Aaron T. Beck, M.D.

University Professor Emeritus of Psychiatry

University of Pennsylvania

and

Director

Cory F. Newman, Ph.D.

Assistant Professor of Psychology in Psychiatry

University of Pennsylvania School of Medicine

and

Clinical Director

Center for Cognitive Therapy

Room 754, The Science Center

3600 Market Street

Philadelphia, PA 19104-2648

Bruce S. Liese, Ph.D.

Associate Professor of Family Practice

and

Director of Behavioral Medicine

Department of Family Practice

University of Kansas Medical Center

39th and Rainbow Boulevard

Kansas City, KS 66103

146
Harm Reduction: Application to

Alcohol Abuse Problems

G. Alan Marlatt, Julian M. Somers, and Susan F. Tapert

“Habit is habit and not to be flung out of the window by any

man, but coaxed downstairs a step at a time.”

Mark Twain (Pudd’nhead Wilson’s Calendar, chapter 6)

DEFINITIONS AND OVERVIEW

The terms “harm reduction,” “harm minimization,” and “risk reduction”

often are used interchangeably in the addictive behaviors literature

(Heather et al. 1993; O’Hare et al. 1992). Although they refer to the

same general approach or model, Europeans (particularly the Dutch)

call it “harm reduction,” the British refer to “harm minimization,” and

Americans are more likely to prefer the term “risk reduction.” In this

chapter, harm reduction is defined as the application of methods

designed to reduce the harm (and risk of harm) associated with

ongoing or active addictive behaviors.

Harm reduction methods are based on the assumption that habits can

be placed along a continuum ranging from temperate to intemperate

use along with associated risks for harm (Marlatt and Tapert 1993).

Figure 1 represents this continuum; the left side represents excess, the

middle part is moderation, and at the farthest point to the right is

abstinence. The risk of harm increases to the left and decreases to the

right along this continuum. The goal of harm reduction programs is to

move the individual with excessive behavior problems from left to

right-to begin to take steps in the right direction to reduce the

harmful consequences of the habit. It is important to note that this

continuum model accepts abstinence as the ultimate risk-reduction

goal. With the exception of eating habits, abstinence greatly reduces

or entirely eliminates the risk of harm from most excessive behaviors.

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FIGURE 1. Continuum of excess, moderation, and abstinence
But the harm reduction model promotes any movement in the right

direction along this continuum as progress, even if total abstinence is

not attained.

Below are, in the authors’ view, some of the emerging themes that

underlie current developments in the field of harm reduction.

1. Harm reduction is broad based and inclusive. As an approach to

considering drug policy, harm reduction encourages the widest

view possible of the varieties of harm associated with drug use and

of ways to reduce this harm. As a function of this broad-based

view, harm reduction provides a conceptual umbrella that

integrates a variety of previously unrelated programs and

techniques, including needle-exchange programs for injection drug

users (IDUs), methadone maintenance treatment for opiate users,

nicotine replacement therapy for smokers, and moderation-oriented

drinking programs for problem drinkers.

2. Harm reduction tends to normalize rather than marginalize

substance users. The harm related to substance use itself often can

be wrenching for the users, their friends and family, and for the

society to which they belong. However, the response to an

individual’s substance use can do much to either exacerbate or

mitigate this harm. Harm reduction approaches acknowledge that,

although it is difficult to eliminate the harm directly related to

substance use, much can be done to eliminate the iatrogenic effects

of interventions while enhancing opportunities for care. Within the

normalization perspective,

. . . drug takers or even addicts should neither be seen as

criminals, nor as dependent patients, but as “normal”

citizens of whom we make “normal” demands and to

whom we offer “normal” opportunities. Addicts should not

be treated as a special category. (Engelsman 1989, p. 215)

In this view, attention is focused on reducing the harmful or risky

consequences of drug use rather than reducing drug use per se.

Drug treatment programs that have “low-threshold” access to care

illustrate this approach. Such programs attempt to address the

health and social well-being of drug users without making these

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3.

4.

services contingent on a commitment to change on the part of the

user. Low-threshold programs make every possible attempt to

include the needs of drug users within the broader context of

health care and social services. For example, outreach workers in

Amsterdam deliver a variety of health-related services and

information to drug users in their communities. These and other

projects “are not primarily intended to end addiction as such, but

to improve addicts’ physical and social well-being and to help

them to function in society” (Engelsman 1989, p. 216).

Harm reduction places substance use on a continuum, relating

levels of use to the severity of problems they engender for each

individual. In this view, reductions in harm can be achieved

incrementally. Although abstinence from drug use may be viewed

as the ultimate objective, significant reductions in personal and

societal harmfulness can be achieved en route to this goal. As

explained by Allan Parry, a leader of harm reduction approaches to

drug addiction and Acquired Immune Deficiency Syndrome

(AIDS) prevention in Liverpool, England:

Harm reduction takes small steps to reduce, even to a

small degree, the harm caused by the use of drugs. If a

person is injecting street heroin of unknown potency, harm

reduction would consider it an advance if the addict were

prescribed safe, legal heroin. A further advantage if he

stopped sharing needles. A further advance if he enrolled

in a needle-exchange scheme. A much further advance if

he moved on to oral drugs or to smoked drugs. A further

advance in harm reduction if he started using condoms and

practicing safe sex practices. A further advance if he took

advantage of the general health services available to

addicts. A wonderful victory if he kicked drugs, although

total victory is not a requirement as it is in the United

States. (Parry 1989, p. 13)

Harm reduction deemphasizes the use of absolute restrictions on

drug use as the primary means of reducing substance use problems.

Many drug policy initiatives propose quantitative goals concerning

substance use such as zero tolerance. Regarding alcohol, an often

acrimonious debate has centered on whether the quantitative goal

150
for problem drinkers should be abstinence in all cases or whether

moderate alcohol consumption is a viable option for this

population. These policies and debates implicitly associate any use

with abuse and fail to discriminate between the different degrees of

harm associated with different levels of substance use. Adding

further complexity to this equation are recent empirical studies that

report good, if not superior, levels of adjustment among individuals

who have experimented with drugs moderately compared with

abstainers or drug abusers (e.g., Shedler and Block 1990). By

avoiding quantitative prescriptions for change, harm reduction

approaches can support any increment of change to reduce

harmfulness. Also, because any degree of positive change is

encouraged, harm reduction reduces the possibility of negative

reactivity by individuals if a quantitative goal such as abstinence is

not achieved or maintained.

HARM REDUCTION METHODS AND AREAS OF

APPLICATION

Harm reduction methods can be employed in tenns of three main areas

of application: (1) AIDS prevention (e.g., safe sex and condom use

programs or needle exchange for IDUs); (2) treatment of ongoing,

active addictive behaviors (e.g., methadone maintenance for opiate

addiction or nicotine replacement therapy for tobacco smokers); and

(3) secondary prevention of harmful addictive or excessive behaviors

(e.g., controlled drinking or moderation of excessive food intake).

Examples of each of these areas are provided below, followed by a

summary of the harm reduction methods involved.

AIDS Prevention

AIDS prevention is one of the most critical examples of harm

reduction (Sorenson et al. 1991). Public health officials around the

world are acknowledging that the crisis of AIDS is more pressing than

the threat of drug addiction or premarital sex, and several harm

reduction measures can be taken to reduce the spread of Human

Immunodeficiency Virus (HIV), including needle exchange, methadone

maintenance treatment programs, and educational prevention programs.

Harm reduction approaches offer at-risk populations simple behavior

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changes that reduce the harm of high-risk activities, often with

abstinence as the end point, but accepting that abstinence is not a

realistic goal for all people. As relapse is common, people need skills

to prevent harm if a relapse should occur. Harm reduction approaches

work to empower rather than marginalize high-risk groups.

Open sex education is an often-controversial form of harm reduction.

Sex education for students in primary and secondary schools has long

been a topic of controversy. The nature of HIV transmission requires

explicit sex education to inform young people, who may or may not be

sexually active, how HIV is transmitted and how they can protect

themselves and others. Sex education that deals with

socioenvironmental influences on behavior (Walter et al. 1991), ideally

accompanied by condom distribution, has been suggested as a major

prevention effort for underage students. However, many school

administrators advocate abstinence from sex despite the fact that more

adolescents report having had sex and having had more partners than

10 years ago (Anderson et al. 1990). A 1989 national survey of 9th

through 12th graders found that 58.5 percent reported having had

sexual intercourse (Anderson et al. 1990). A recent national high

school sample found that 2.7 percent reported having ever injected

illicit drugs. Students who reported having learned about HIV in

school were significantly less likely to report having ever injected

drugs and having ever shared needles, reported fewer sexual partners,

and were more likely to use condoms (Holtzman et al. 1991).

Approximately 19.5 percent of U.S. AIDS cases to date were

diagnosed in the 20- to 29-year age bracket, and many of these may

have contracted HIV during their teenage years (Centers for Disease

Control 1992). The spread of HIV could be stemmed by open sex

education and HIV prevention programs that do not encourage sexual

activity but acknowledge its presence among people of all ages while

providing useful information and skills along with the tools necessary

to have safe sex (condoms).

Treatment of Ongoing Addictive Behaviors

Harm reduction methods can be applied to the treatment of addiction

problems in addition to AIDS prevention. Nonabstinent goals to

reduce risk of harm include: (a) changing the route of drug

administration, (b) providing alternative, “safer” substances, and (c)

152
reducing the frequency or intensity (quantity and dose level) or both of

ongoing addictive behaviors. Although space does not permit a full

discussion of each of these goals, a brief description of some examples

may help clarify these methods.

In the first example, the goal is to reduce the harm of ongoing

addictive behavior by changing the route of administration of the

substance or drug. In AIDS prevention, needle exchange is the most

obvious example: clean needles and syringes are used to administer

injection drugs in place of dirty or shared needles (cf. Battjes and

Pickens 1988; Brettle 1991; Stimson 1989). Another example is

smoking or orally consuming drugs instead of using the injection

method of administration. In the Merseyside region of Northwestern

England, pharmacists provide drug clinics with noninjectable drugs in

the form of “reefers” (herbal or tobacco cigarettes injected with heroin,

methadone, cocaine, or amphetamine). Reefers are prescribed through

drug dependency units located in Liverpool and other Merseyside

hospitals or in self-contained units near town centers. For those who

cannot immediately give up injecting drugs, a combined injection and

reefer prescription can be given. For users who are able to move

toward stabilizing on oral drugs, a combined oral and reefer

prescription can be used (Canadian Center on Substance Abuse 1991).

The Liverpool model of harm reduction has pioneered the policy of

making illicit drugs available to addicts on a controlled basis (Marks

1991).

A related treatment method for nicotine dependence is nicotine

replacement therapy (Benowitz 1988). Nicotine replacement therapy

changes the route of administration of nicotine from smoking to either

nicotine gum or a transdermal nicotine patch. The risk of cancer

associated with smoking is thereby reduced by changing the method of

drug ingestion. Although this form of treatment is recommended as a

method of reducing withdrawal symptoms associated with smoking

cessation with the eventual goal of abstinence, some smokers may

maintain ongoing use with these replacement strategies or use them as

a way of reducing intake or tapering down (Gross and Stitzer 1989;

Russell 1991).

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A second goal of nonabstinence harm reduction methods is the

provision of a safer alternative substance or drug to replace the more

harmful substance. The Dutch approach to decriminalizing cannabis

use is an illustration of this approach. Here the rationale is that

providing “soft drugs” as a means of experimenting with intoxicating

substances will prevent users from turning to substances of higher risk

such as cocaine or heroin (Engelsman 1989). The same argument

applies to alcohol: programs that recommend moderate consumption

of beverages low in alcohol content (e.g., wine and beer) promote

alternatives to the excessive use of stronger beverages (e.g., distilled

spirits).

Perhaps the most widely known example of this method is methadone

maintenance as an alternative to opiate injection or heroin use.

Methadone reduces risks associated with illicit substance use and

injection and provides a realistic option for some drug users. Many

clients report preferring this form of treatment to drug-free treatments

(Chaney and Roszell 1985; Mavis et al. 1991). Methadone dispensing

programs utilizing contingency contracting interventions that use

urinalysis to test for illicit drug use have been indicated as most

successful in keeping clients from using illicit drugs (Dolan et al.

1985; Higgins et al. 1986). Positive reinforcement by increasing

methadone dosages for negative urinalyses has been shown to reduce

dropout rates (Stitzer et al. 1986).

Secondary Prevention and Harm Reduction

The third goal of harm reduction applies both to the secondary

prevention and treatment of addictive behaviors: to reduce the

frequency or intensity or both of the target behavior. Risk-reduction

programs based on moderation or responsible-use principles have been

applied in prevention programs geared toward alcohol use (see below).

Similar principles have been applied in promoting moderate food

consumption for overweight individuals or those who have binge

eating problems (cf. Brownell and Foreyt 1986). In addition, sex

education for AIDS prevention may focus on reducing the frequency of

high-risk sexual activity (e.g., promoting monogamous sex, reducing

the number of unsafe sexual episodes, or moving toward less risky

forms of sex).

154
One of the most controversial harm-reduction strategies is controlled or

moderate drinking as an alternative to abstinence for people with

alcohol problems (Heather and Robertson 1983; Marlatt 1983; Marlatt

et al. 1993; Sobell and Sobell 1978). In the treatment of alcohol

dependence in the United States, controlled drinking programs are

rarely available compared to other countries (e.g., Canada, Australia,

and many European countries). The bulk of the resistance to this

approach stems from abstinence advocates of the medical model, who

view alcoholism as a progressive disease that cannot be cured (i.e.,

moderation can never be attained by “recovering” alcoholics).

According to these critics, abstinence is the only acceptable goal for

both treatment and prevention-no amount of moderation training can

stem the tide of this insidious disease.

One of the apparent paradoxes of controlled drinking programs for

problem drinkers is that many clients exposed to this approach

eventually end up abstaining from alcohol (Miller et al. 1992). From

the perspective of harm reduction theory, such a “paradoxical” outcome

is not surprising. Problem drinkers who otherwise might resist the

high-threshold commitment to abstinence as a precondition for

treatment or participation in an abstinence-based self-help group may

well be attracted by a moderation program instead. Once they have

entered such a low-threshold program and are taking steps in the right

direction, it is little wonder that many of these clients end up abstinent.

Many of the skills and coping strategies employed in these

cognitive-behavioral programs can be used to foster both moderation

and abstinence goals (cf. Nathan and McCrady 1987). The greater the

number of options available to the large mass of otherwise unreachable

problem drinkers, the more people will be motivated to seek help for

their drinking. Instead of requiring that clients uniformly quit in a

“cold turkey” approach, harm reduction provides the client with

options to taper their use gradually, to opt for a “warm turkey”

alternative route to quitting (Miller and Page 1991).

ALCOHOL AND YOUTH

Within the United States, the consumption of alcohol by young people

is associated with numerous health problems, including alcohol-related

accidents, academic failure, vandalism, relationship difficulties, and

155
acquaintance rape (Institute of Medicine 1990). Alcohol-related

accidents are the leading cause of death among youth (National

Institute on Alcohol Abuse and Alcoholism 1984). Alcohol is also the

drug of choice among American youth. While the use of most illicit

drugs has declined over the past decade, self-reported alcohol

consumption has remained relatively constant (Johnston et al. 1989).

Of particular concern to health officials has been the pattern of

drinking among youth, which often involves large quantities of alcohol

consumed relatively infrequently. A pattern of so-called binge

drinking has been identified among this group. If binge drinking is

defined as having five or more drinks in a row during the previous 2

weeks, it has been reported that 41 percent of America’s college

students and 34 percent of their noncollege counterparts engage in

binge drinking (Johnston et al. 1991). Although the frequency of

binge drinking appears to have decreased in individuals of college age

who are not enrolled in college between 1980 and the present, the

frequency of this behavior among college students has remained

relatively constant (Johnston et al. 1989). Moreover, between 1977

and 1989 the proportion of college students reporting that they drink to

get drunk has increased two to three times, reflected in the finding that

students drank greater quantities of alcohol with greater regularity in

1989 than in 1977 (Wechsler and Isaac 1992). These trends have

prompted Federal Government agencies to recommend stricter legal

controls on the availability of alcohol to youth and greater enforcement

of punishment for the consumption of alcohol by those under the age

of 21 (Kusserow 1991). Additional programs sponsored by the Federal

Government are targeted at reducing binge drinking among college

students (Eigen and Quinlan 1991).

Although there is agreement among college administrators, health

officials, and others that the consumption of alcohol by college

students constitutes a serious problem, there is little agreement

regarding what to do about substance use among young people in

general. In a recent comprehensive review of the treatment and

prevention literature, the Institute of Medicine reported:

There is perhaps no special population about which so much

has been written; yet, despite the more than 2,000 published

papers, the common feeling among investigators in this area is

156
that very little is known about how best to treat youth with

alcohol and other drug problems. (Institute of Medicine 1990,

p. 359)

Many existing alcohol treatment facilities for youth are modeled on

adult residential programs. However, the appropriateness of these

programs for young people has been challenged on a number of points

(e.g., Durst 1988; Woltzen et al. 1986). Several unique characteristics

of college-age drinkers have been identified (see Marlatt 1988) that

may support certain styles of intervention and contraindicate others.

The pattern of drinking among college students, as well as the

problems that they are likely to experience, is different from those of

older problem drinkers. In contrast to the classic symptoms of alcohol

dependence (e.g., daily drinking and withdrawal), college students are

more likely to experience more acute alcohol-related problems relating

to drinking in certain times and settings (e.g., weekend parties). Most

collegians will fail to identify themselves as problem drinkers, and the

labeling of young persons as “alcoholic” may restrict their

opportunities to mature out of heavy drinking in the modal fashion

(e.g., Fillmore et al. 1979). Also, because many college drinkers are

under 21 years of age, they are engaging in illegal behavior. This

legal conflict has led several important national organizations to

denounce “responsible drinking” as a viable objective for underage

collegians. In the absence of alternative sources of information,

students tend to develop their drinking habits based on the behavior of

peers as well as media depictions of drinking norms.

Among the challenges faced by those working with college drinkers

are: (1) how to motivate students to participate in alcohol-related

programs when students do not perceive themselves to have a problem,

(2) how to moderate and, in some cases, challenge the influence of

peer norms and media depictions, and (3) how to accelerate rather than

impede the process of maturing out of risky drinking behavior.

Another difficulty faced by workers in this area arises from the

illegality of underage drinking. Options for intervention are limited

because of the official position that the behavior under consideration

should not occur in the first place. In this view, programs that attempt

to develop responsible drinking habits are seen as promoting rather

than solving the problem. Similar arguments are familiar to

proponents of condom distribution and needle exchange programs.

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THE HIGH RISK DRINKERS PROJECT

The High Risk Drinkers Project is a campus-based program for the

reduction of alcohol-related problems among members of the

University of Washington community (Marlatt et al., in press). This

project has applied many of the principles of harm reduction to provide

an alternative to traditional services for this population. Because

alcohol use is associated with normal development among students, a

program was developed in which a variety of risk factors and problems

are assessed but labels such as “problem drinking” or “alcoholic” are

avoided. As in other harm reduction approaches, this program

attempts to place both alcohol-related problems and varieties of

interventions on a continuum. Attempts are made to match individuals

to levels of care based on the extent of their alcohol-related problems

and, significantly, their willingness to receive any form of help or

treatment.

In order to test the efficacy of this approach, a longitudinal study was

conducted involving more than 400 students who entered the

University of Washington as freshmen in 1990 (cf. Baer 1993).

Students were selected from among the entire incoming class based on

their reports of risky high school drinking or their experience of

negative alcohol-related consequences prior to entering the university.

Because the members of the sample are at increased risk for

experiencing alcohol-related problems, this study is one of secondary

prevention.

One of the features of many harm reduction programs is the utilization

of low-threshold services. It is essential that the criteria for receiving

services do not exceed the interest or commitment level of potential

recipients. In this sample, few students would identify themselves as

candidates for any form of treatment. In order to encourage students

to participate in the program, the authors have developed a userfriendly stepped-care approach that is modeled after existing

therapeutic practices for hypertension (see Sobell and Sobell 1993).

The first step of the program consists of a single hour in which each

subject meets with a member of the staff to receive feedback

concerning his or her drinking risks and to review practices for

reducing harm. Previous research has shown that brief interventions

can have a significant and enduring impact on drinking habits (Baer et

158
al. 1992). Subsequent levels of care are available to subjects if the

initial intervention is not sufficiently effective.

The therapeutic style is based largely on the principles of motivational

interviewing (Miller and Rollnick 1991). This technique is designed to

cultivate and strengthen an individual’s level of commitment to

change. Consistent with Prochaska and DiClemente’s (1982) model of

the stages of behavior change, the motivational interviewer’s task is to

help an individual advance from considering change to attempting

change. Prochaska and DiClemente (1982) describe several levels of

preparedness for change that individuals may pass through:

precontemplation, in which change is not being considered;

contemplation, in which the idea of changing emerges; action, in which

some attempt to change is made; maintenance, in which successful

actions are maintained; and relapse, in which the previous undesired

behavior reemerges. Consistent with harm reduction, any movement

toward taking and maintaining action is viewed positively.

Preliminary results of this ongoing project indicate that students

assigned to the stepped-care program reported significantly lower

levels of drinking after 2 years than students in a randomly assigned

comparison group (Marlatt et al., in press). A measure of

alcohol-related problems (the Rutgers Alcohol Problem Index; White

and Labouvie 1989) recorded a similar decline among students

receiving this intervention versus a comparison group.

Consistent with the above mentioned motivational orientation, a

considerable part of clinical attention goes toward maintaining good

rapport with the subjects. If an individual continues to report risky

drinking practices or negative consequences of alcohol use subsequent

to the initial interview, the student is advised and an attempt is made

to engage the individual in a discussion of what might be the best

course of action to take. A range of options is presented, but the

decision to undertake any action is left to the student. This clinical

style is informed by a body of research in the addictions field that

underscores the importance of commitment to change as a contributor

to the ultimate success of any program (Hall et al. 1990, 1991).

Certain parallels may be evident between this secondary prevention

program, programs such as needle exchange to prevent the spread of

159
HIV, and tertiary prevention programs such as the mobile methadone

clinics in Amsterdam. In each case, the program makes an attempt to

enter the lives of the persons who might benefit from its services. The

practitioners of these programs, like therapists of many schools, are

advocates for the individuals they serve. Services and information are

made available but are not forced on people.

For example, the workers who staff Amsterdam’s mobile methadone

clinics become personally familiar with many of the addicts that they

serve and offer encouragement for change in addition to multiple

services such as exchanging needles, administering oral doses of

methadone, and providing condoms and first aid supplies. A great

benefit of this approach is that a large proportion of the target

population is in contact with some form of health promotion agency

(Marlatt and Tapert 1993). In Amsterdam, it is estimated that 60 to 80

percent of IDUs are in contact with health agencies (Engelsman 1989,

p. 217). This proximity greatly enhances the opportunities for care

that may be administered. It also illustrates a type of societal response

to drug-related problems that avoids alienating individuals by

identifying them as either sick or criminal, but seeing them instead as

people who are part of society and who need help.

HARM REDUCTION AND AMERICAN DRUG POLICIES

In 1992, the United States budgeted $11,680 million for Federal drug

programs, 70 percent of which was allotted to interdiction and law

enforcement and 30 percent of which went toward education and

treatment programs. This division of resources will do little to reduce

the numerous impediments to treatment for addicts and IDUs in the

United States. More than 107,000 individuals were on waiting lists for

treatment in 1991 (National Commission on AIDS 1991), but there are

vastly more individuals who might benefit from some care. New York

City has an estimated 200,000 IDUs but only 38,000 publicly funded

treatment positions. Inadequate funding is only one of the factors that

limits access to proper health care for drug users: needle exchange

programs remain illegal in many cities and States; most treatment

programs require abstinence as a condition of admission or

continuation of services; the most widely available forms of treatment

in the United States tend to incorporate disease model concepts or

160
involve submission to a “higher power,” which many individuals find

personally objectionable; and the threat of arrest and possible

imprisonment for use deters many (e.g., pregnant females who may

fear prosecution for child abuse). In contrast to low-threshold policies

advocated under harm reduction. U.S. drug policy sets a very high

threshold on drug-related services.

Beyond the harm that is done by underfunding treatment and

educational programs, it is apparent that considerable harm is being

added, rather than alleviated, by spending vast sums on interdiction

and law enforcement. The persecution of addicts and recreational drug

users alike is exacting an inconceivably high toll and is fiscally

irresponsible because prison is a tremendously expensive form of

treatment that is also demonstrably ineffective.

NOTE

This paper is based on material from the chapter “Harm reduction:

Reducing the risks of addictive behaviors” by G.A. Marlatt and S.F.

Tapert in Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds. Addictive

Behaviors Across the Lifespan: Prevention, Treatment, and Policy

Issues. Newbury Park, CA: Sage Publications, 1993. pp. 243-273.

REFERENCES

Anderson, J.E.; Kann, L.; Holtzman, D.; Arday, S.; Truman, B.; and

Kolbe, L.J. HIV/AIDS knowledge and sexual behavior among high

school students. Fam Plann Perspect 22:252-255, 1990.

Baer, J.S. Etiology and secondary prevention of alcohol problems with

young adults. In: Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds.

Addictive Behaviors Across the Lifespan: Prevention, Treatment,

and Policy Issues. Newbury Park, CA: Sage Publications, 1993.

pp. 111-137.

Baer, J.S.; Marlatt, G.A.; Kivlahan, D.R.; Fromme, K.; Larimer, M.;

and Williams, E. An experimental test of three methods of alcohol

risk-education with young adults. J Consult Clin Psychol 60:974-

979, 1992.

161
Battjes, R.J., and Pickens, R.W. Needle sharing among intravenous

drug abusers: Future directions. In: Battjes, R.J., and Pickens, R.W.,

eds. Needle Sharing Among Intravenous Drug Abusers: National

and International Perspectives. National Institute on Drug Abuse

Research Monograph 80. DHHS Pub. No. (ADM)88-1567.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp.

176-183.

Benowitz, N.L. Drug therapy: Pharmacologic aspects of cigarette

smoking and nicotine addiction. New Engl J Med 319:1318-1330,

1988.

Brettle, R.P. HIV and harm reduction for injection drug users. AIDS

5:125-136, 1991.

Brownell, K.D., and Foreyt, J.P., eds. Handbook of Eating Disorders.

New York: Basic Books, 1986.

Canadian Center on Substance Abuse. Harm reduction strategies:

Smokable drugs help reduce spread of HIV in Merseyside. News

Action 11(4):7, 1991.

Centers for Disease Control. HIV/AIDS Surveillance Report. Atlanta:

Division of HIV/AIDS, National Center for Infectious Diseases,

Centers for Disease Control, April 1992.

Chaney, E.F., and Roszell, D.K. Coping in opiate addicts maintained

on methadone. In: Shiffman, S., ed. Coping and Substance Use.

Orlando, FL: Academic Press, 1985. pp. 267-292.

Dolan, M.P.; Black, J.L.; Penk, W.E.; Robinowitz, R.; and DeFord,

H.A. Contracting for treatment termination to reduce illicit drug use

among methadone maintenance treatment failures. J Consult Clin

Psychol 53:549-551, 1985.

Durst, M.E. “Statement Presented on Behalf of the National Council on

Juvenile and Family Court Judges.” Presented at the Open Meeting

of the I.O.M. Committee for the Study of Treatment and

Rehabilitation Services for Alcoholism and Alcohol Abuse,

Washington, DC, January 1988.

Eigen, L.D., and Quinlan, J.W. OSAP college drinking campaign: “Put

on the brakes: Take a look at college drinking!” Alcohol Health Res

World 15:87-89, 1991.

Engelsman, E.L. Dutch policy on the management of drug-related

problems. Br J Addict 84:211-218, 1989.

162
Fillmore, K.M.; Bacon, S.D.; and Hyman, M. The 27-Year

Longitudinal Panel Study of Drinking by Students in College,

1949-1976. Final report to National Institute on Alcohol Abuse and

Alcoholism (Contract no. ADM 281-76-0015). Rockville, MD:

National Institute on Alcohol Abuse and Alcoholism, 1979.

Gross, J., and Stitzer, M.L. Nicotine replacement: Ten-week effects on

tobacco withdrawal symptoms. Psychopharmacology 98:334-341,

1989.

Hall, S.; Havassy, B.; and Wasserman, D. Commitment to abstinence

and acute stress in relapse to alcohol, opiates, and nicotine.

J Consult Clin Psychol 58: 175-181, 1990.

Hall, S.; Havassy, B.; and Wasserman, D. Effects of commitment to

abstinence, positive moods, stress, and coping on relapse to cocaine

use. J Consult Clin Psychol 59:526-532, 1991.

Heather, N., and Robertson, I. Controlled Drinking. London: Methuen,

1983.

Heather, N.; Wodak, A.; Nadelmann, E.; and O’Hare, P., eds.

Psychoactive Drugs and Harm Reduction. London: Whurr

Publishers, 1993.

Higgins, S.T.; Stitzer, M.L.; Bigelow, G.E.; and Liebson, I.A.

Contingent methadone delivery: Effects on illicit-opiate use. Drug

Alcohol Depend 17:311-322, 1986.

Holtzman, D.; Anderson, J.E.; Kann, L.; Arday, S.L.; Truman, B.I.;

and Kolbe, L.J. HIV instruction, HIV knowledge, and drug injection

among high school students in the United States. Am J Public

Health 81:1596-1601, 1991.

Institute of Medicine. Broadening the Base of Treatment for Alcohol

Problems. Washington, DC: National Academy Press, 1990.

Johnston, L.D.; Bachman, J.G.; and O’Malley, P.M. Drug Use,

Drinking and Smoking: National Survey Results From High School,

College, and Young Adult Populations. DHHS Pub. No.

(ADM)89-1638. Rockville, MD: National Institute on Drug Abuse,

1991.

Johnston, L.D.; O’Malley, D.M.; and Bachman, J.G. Drug Use,

Drinking and Smoking: National Survey Results From High School,

College, and Young Adult Populations, 1975-1988. DHHS Pub. No.

(ADM)89-1638. Rockville, MD: Alcohol, Drug Abuse, and Mental

Health Administration, 1989.

163
Kusserow, R.P. Youth and Alcohol: National Survey: Drinking Habits,

Access, Attitudes, and Knowledge. DHHS Pub. No.

OEI-09-91-00652. Washington, DC: Office of the Inspector

General, 1991.

Marks, J. The practice of controlled availability of illicit drugs. In:

Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the

Addictive Behaviors. New York: Maxwell Macmillan International

Publishing Group, 1991. pp. 304-316.

Marlatt, G.A. The controlled drinking controversy: A commentary.

Am Psychol 38:1097-l110, 1983.

Marlatt, G.A. “Executive Summary: College Students as a High Risk

Group.” Summary prepared for the Institute of Medicine Committee

for the Study of Treatment and Rehabilitation Services for

Alcoholism and Alcohol Abuse, April 1988.

Marlatt, G.A.; Larimer, M.E.; Baer, J.S.; and Quigley, L.A. Harm

reduction: Moving beyond the controlled drinking controversy.

Behav Ther, in press.

Marlatt, G.A., and Tapert, S.F. Harm reduction: Reducing the risks of

Addictive Behaviors. In: Baer, J.S.; Marlatt, G.A.; and McMahon,

R.J., eds. Addictive Behaviors Across the Lifespan: Prevention,

Treatment, and Policy Issues. Newbury Park, CA: Sage

Publications, 1993.

Mavis, B.E.; DeVoss, G.H.; and Stoffelmayr, B.E. The perceptions of

program directors and clients regarding the efficacy of methadone

treatment. Int J Addict 26:769-776, 1991.

Miller, W.R.; Leckman, A.L.; Delaney, H.D.; and Tinkcom, M.

Long-term follow-up of behavioral self-control training. J Stud

Alcohol 53:249-261, 1992.

Miller, W.R., and Page, A.C. Warm turkey: Other routes to abstinence.

J Subst Abuse Treat 8:227-232, 1991.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing

People for Change. New York: Guilford, 1991.

Nathan, P.E., and McCrady, B.S. Bases for use of abstinence as a goal

in the behavioral treatment of alcohol abusers. Drugs and Society

1:109-131, 1987.

National Commission on AIDS. The Twin Epidemics of Substance Use

and HIV. Washington, DC: National Commission on AIDS, 1991.

164
National Institute on Alcohol Abuse and Alcoholism. Report of the

1983 Prevention Planning Panel. Rockville, MD: National Institute

on Alcohol Abuse and Alcoholism, 1984.

O’Hare, P.A.; Newcombe, R.; Matthews, A.; Buning, R.C.; and

Drucker, E. The Reduction of Drug-Related Harm. London:

Routledge, 1992.

Parry, A. Harm reduction. The Drug Policy Letter (Washington, DC:

The Drug Policy Foundation) 1, no. 4 (1989):13.

Prochaska, J.O., and DiClemente, C.C. Toward a comprehensive model

of change. In: Miller, W.R., and Heather, N., eds. Treating

Addictive Behaviors. New York: Plenum Press, 1982. pp. 3-27.

Russell, M.A.H. The future of nicotine replacement. Br J Addict

86:653-658, 1991.

Shedler, J., and Block, J. Adolescent drug use and psychological

health: A longitudinal inquiry. Am Psychol 45:612-630, 1990.

Sobell, M.B., and Sobell, L.C. Behavioral Treatment of Alcohol

Problems. New York: Plenum Press, 1978.

Sobell, M.B., and Sobell, L.C. Treatment for problem drinkers: A

public health priority. In: Baer, J.S.; Marlatt, G.A.; and McMahon,

R.J., eds. Addictive Behaviors Across the Lifespan: Prevention,

Treatment, and Policy Issues. Newbury Park, CA: Sage

Publications, 1993. pp. 138-160.

Sorenson, J.L.; Wermuth, L.A.; Gibson, D.R.; Choi, K.H.; Guydish,

J.R.; and Batki, S.L. Preventing AIDS in Drug Users and Their

Sexual Partners. New York: Guilford, 1991.

Stimson, G.V. Syringe-exchange programmes for injecting drug users.

AIDS 3:253-260, 1989.

Stitzer, M.L.; Bickel, W.K.; Bigelow, G.E.; and Liebson, I.A. Effect of

methadone dose contingencies on urinalysis test results of

polydrug-abusing methadone-maintenance patients. Drug Alcohol

Depend 18:341-348, 1986.

Walter, H.J.; Vaughan, R.D.; Gladis, M.M.; Ragin, D.F.; Kasen, S.;

and Cohall, A.T. Factors associated with AIDS risk behaviors

among high school students in an AIDS epicenter. Am J Public

Health 81:528-532, 1991.

Wechsler, H., and Isaac, N. “Binge” drinkers at Massachusetts

colleges: Prevalence, drinking style, time trends, and associated

problems. JAMA 267:2929-2931, 1992.

White, H.R., and Labouvie, E.W. Towards the assessment of

adolescent problem drinking. J Stud Alcohol 50:30-37, 1989.

165
Woltzen, MC.; Filstead, W.J.; Anderson, C.L.; Twadell, S.; Sisson, C.;

and Zoch, P. Clinical issues central to the residential treatment of

alcohol and substance misusers. Adv Adolesc Ment Health

2:271-282, 1986.

AUTHORS

G. Alan Marlatt, Ph.D.

Professor of Psychology

and

Director

The Addictive Behaviors Research Center

Julian M. Somers, M.S.

Graduate Research Assistant

Susan F. Tapert, B.A.

Undergraduate Research Assistant

Department of Psychology

University of Washington

Seattle, WA 98195

166
Behavioral Treatments for Drug

Problems: Lessons From the

Alcohol Treatment Outcome

Literature

William R. Miller

INTRODUCTION

There are striking parallels in the nature, etiology, and course of

addictive behaviors. Alcohol, tobacco, and other drug problems

overlap substantially in epidemiology, are all influenced by a

combination of biomedical and psychosocial factors, involve impaired

personal control, and are characterized by high rates of relapse

(Brownell et al. 1986; Miller 1980). These similarities extend to a

broader range of compulsive behaviors (Heather et al. 1991; Orford

1985; Peele 1985).

Yet, both treatment programs and research for alcohol versus other

drug problems have developed with an astonishing degree of isolation.

Although clients of the Center on Alcoholism, Substance Abuse, and

Addictions are increasingly difficult to classify as alcohol versus other

drug abusers and there is increasing public recognition that alcohol is a

drug, there remain separate treatment systems and staffs, research

institutes, and self-help organizations. Markedly different emphases

have evolved for both treatment and prevention strategies. The reasons

for this partition arise from historical and political events rather than

from compelling differences inherent in the problems and clients.

In considering how to advance behavioral treatment for drug abuse and

dependence, it may be informative to consider the state of research

knowledge in treatment related to one particular drug: alcohol.

Treatment research is well developed in the alcohol field; currently,

more than 250 controlled trials have been published. Behavioral

treatments in particular are well studied, comprising more than half of

the trials to date. For several behavioral strategies, dismantling

167
research has been conducted to examine theoretical and practical

foundations of efficacy. Alcohol treatment assessment technology has

advanced substantially during the past two decades, permitting better

quantification of outcomes. Further, important gains have been made

in knowledge on the interaction of client and treatment characteristics

(“treatment matching”), and a multisite collaborative trial on this

subject is underway at the National Institute on Alcohol Abuse and

Alcoholism (NIAAA).

This chapter will summarize this broad literature on alcohol treatment

outcome, emphasizing behavioral treatments. It also will highlight

issues that have emerged along the way, which may be informative for

research and practice in the behavioral treatment of drug problems

more generally.

TREATMENT OUTCOME REVIEWS

Reviews of the alcohol treatment outcome literature have progressed

through several stages. The first-generation reviews were narrative

summaries of findings with some commentary on methodology

(e.g., Baekeland 1977; Bowman and Jellinek 1941; Voegtlin and

Lemere 1941). As studies accumulated, a second wave of reviewers

attempted to derive average outcome statistics for treatment in general

or for particular modalities, but these reviews remained largely

narrative (Costello et al. 1977; Emrick 1974, 1975; Miller and Hester

1980).

In an attempt to discern more reliable patterns, Miller and Hester

(1986a) provided a narrative review restricted to controlled

trials-comparisons of two or more groups that were equated before

treatment by randomization or matching. This review concluded that

only six treatment methods were “currently supported by controlled

outcome research”: aversion therapies, behavioral self-control training,

the community reinforcement approach, behavioral marital therapy,

social skills training, and stress management. It is noteworthy that all

six of these are behavior therapies. This list was contrasted with

“treatment methods currently employed as standard practice in

alcoholism programs”: the 12-step method, alcoholism education,

confrontation, disulfiram, group therapy, and individual

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counseling-none of which, it was concluded, were then adequately

supported as effective treatment modalities by controlled research

(Miller and Hester 1986a, p. 162).

A subsequent review by Holder and colleagues (1991) added two

dimensions. First, controlled studies pertaining to each treatment

modality were classified as positive or negative trials, and a weighted

evidence index (WEIn) was compiled for each modality as a kind of

box score of efficacy. Second, through the polling of clinical experts,

the optimal number and type of units of service required to deliver

each modality were determined, and these units were costed to estimate

the average cost (not price) of delivery for each modality. This

permitted the construction of a grid in which treatment modalities were

located in two-dimensional space according to cost category and

evidence for efficacy (WEIn). The 10 modalities judged to have good

or fair evidence of effectiveness included all six previously identified

by Miller and Hester (1986a), as well as behavior contracting, brief

motivational counseling, antidepressant medication, and disulfiram. A

striking finding was a significant negative correlation (r = -.385,

p < .05) between the cost and effectiveness of modalities. Like the

National Academy of Sciences (1990), Holder and colleagues (1991)

concluded that it is wrong to ask: “Is alcoholism treatment (cost-)

effective?” Treatment modalities appear to differ dramatically in both

cost and effectiveness, and no blanket endorsement can be given for

“treatment.” They recommended instead focusing on the question,

“Which alcoholism treatment modalities are most effective for the least

cost?” (Holder et al. 1991, p. 533)

None of these reviews took into account the methodologic quality of

studies in other than a narrative way. Thus, in the Holder and

colleagues (1991) analysis, a poorly designed and conducted study was

given the same weight in a modality’s WEIn score as a study with

exemplary design and performance. Two reviews are currently

underway to take this next step: one at The University of New

Mexico (UNM) and one at the National Drug and Alcohol Research

Centre (NDARC) in Sydney, Australia. Using different approaches,

each group is classifying studies on a variety of methodologic

dimensions, with plans to use these ratings to improve the

interpretation of study outcomes.

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The plan at UNM is to calculate cross-products of methodologic

strength scores and a treatment outcome classification. A sum of these

cross-products, interpreted in relation to the total volume of research

conducted, will provide a more refined index of research evidence for

the efficacy of each modality.

The NDARC group, under the direction of Dr. Richard Mattick, is

adding another important dimension to its review: the calculation of

effect sizes. This will be the first comprehensive review of outcome

literature in this area to include effect sizes. Furthermore, the reviews

encompass treatments for alcohol, tobacco, and other drugs.

PROMISING BEHAVIORAL STRATEGIES

From these reviews, what behavioral approaches appear to be most

promising? Supported modalities can be grouped subjectively into two

general strategies:

1. Treatments designed to suppress use:

Antidipsotropic medication with compliance contracting,

Aversion therapies (covert sensitization),

Behavior contracting,

Behavioral self-control training, and

Brief motivational counseling.

2. Methods to teach skills for successful sober living:

Behavioral marital therapy,

Community reinforcement approach,

Social skills training, and

Stress management training.

All five modalities designed to suppress use are readily applicable to

other drug problems. Pharmacologic parallels to disulfiram are drug

antagonists or agonist/antagonist combinations. The principal problem

in the use of medications such as disulfiram and naltrexone is

compliance. Various procedures have been used to increase disulfiram

compliance, including behavior contracting, spouse monitoring and

170
encouragement, more frequent clinic visits with monitoring, and

implantation (Fuller 1989). Behavior contracting more generally has

been found helpful in maintaining sobriety, and it is a familiar

approach in treating drug abuse.

Aversion therapies have a long and controversial history. Holder and

colleagues (1991) found adequate experimental support for covert

sensitization, the only form of aversion therapy that involves no

physical unconditioned stimulus but is conducted in imagination. It

clearly is possible to induce a conditioned aversion reaction through

covert sensitization, and the establishment of conditioning has been

found to be predictive of favorable outcome (Elkins 1980; Miller and

Dougher 1989). More broadly, conditioning-based procedures

(e.g., cue exposure) have been explored as relevant processes in

treatment for alcohol and other drug problems (Greeley and Westbrook

1991).

Behavioral self-control training (BSCT) involves teaching learningbased procedures to clients to assist them in altering their own

behavior. In the Holder and colleagues (1991) review, BSCT had the

largest number of trials (17) and the second highest WEIn score (after

social skills training) of any modality. BSCT has most often been

applied with a goal of moderation of alcohol use (Hester and Miller

1989) or other drug use (Wilkinson and LeBreton 1986), but it also

has been applied with a goal of abstinence (e.g., Sanchez-Craig et al.

1984). Typically, BSCT includes a combination of strategies designed

to modulate use (e.g., specific goal-setting, self-monitoring, alteration

of the topography of use, stimulus control, self-reinforcement, and

refusal training) and methods for altering the probability of future use

(e.g., functional analysis and coping skill training). Applications to

other drug use are straightforward.

The success of brief counseling in altering problem drinking has been

documented consistently. In a recently completed review, Bien and

colleagues (in press) identified 32 controlled trials with strikingly

consistent results. The methodology of these studies compares

favorably with that for the alcohol field in general (mean of 13 on a

composite methodologic quality scale of 0-17). Brief counseling

(typically one to three sessions) has been found consistently superior to

untreated controls and in 11 of 13 randomized trials has had

171
comparable impact to that of more extensive treatments. These brief

interventions have included virtually no behavioral skill training,

medication, or contracting. Their content is more cognitivemotivational (Miller and Rollnick 1991). Six elements, summarized in

the acronym FRAMES, have been described as common components

of effective brief interventions (Miller and Sanchez, in press):

FEEDBACK of personal assessment results,

Emphasis on personal RESPONSIBILITY for change,

ADVICE to change use,

Description of a MENU of options for change,

Therapeutic EMPATHY as a predominant counseling style, and

Support for client SELF-EFFICACY and optimism.

In the Holder and colleagues (1991) grid, brief motivational counseling

was the only entry in the box with highest evidence of efficacy and

lowest cost. Researchers at UNM have developed and tested a

“Drinker’s Check-up” to manifest the FRAMES elements (Miller and

Sovereign 1989; Miller et al., in press) and are exploring the extension

of this model to a brief intervention for other drug use.

All four effective behavioral methods that support a sober lifestyle are

also readily applicable in the treatment of drug problems in general.

Behavioral marital therapy teaches skills for more effective

communication and positive reinforcement within intimate relationships

(O’Farrell and Cowles 1989). Social skills training focuses more

generally on communication skills such as assertiveness for effective

social relations (Monti et al. 1986). Studies of stress management

procedures in alcohol treatment have focused primarily on relaxation

training and systematic desensitization, although a broader array of

technologies can be applied (Stockwell and Town 1989). Azrin’s

community reinforcement approach, which has yielded some of the

largest treatment effects in the literature, combines many of the wellsupported components described above, including monitored

disulfiram, behavior contracting, motivational counseling, behavioral

marital therapy, social skills training, and mood management (Sisson

and Azrin 1989). As with other behavioral strategies, the community

reinforcement approach can be applied directly in the treatment of

other drug problems (e.g., Higgins et al. 1991). Investigators at UNM

currently are conducting three clinical trials of this approach with

172
alcoholics (R0l-AA07564), heroin addicts (R18-DA06953), and dually

diagnosed homeless individuals (R0l-AA08331).

CONTRAST WITH STANDARD PRACTICE

The presence of a large body of treatment outcome research in general,

and of behavioral treatment studies in particular, has had little apparent

impact on standard practice. Alcoholism treatment programs continue

to rely on a reasonably standard (if unspecified) melange of counseling

strategies loosely derived from psychodynamic and disease model

conceptions that have changed surprisingly little in 50 years (Miller, in

press-a). Group therapy is a common program component, often

emphasizing confrontation of denial, group processes, and general

exploration and expression of emotions (e.g., “inner child” work)–

themes frequently pursued in individual counseling as well.

Educational lectures and films are likewise normative, typically

teaching an attributional model that emphasizes a unitary disease that

is biologically based and involves irreversible loss of control (Miller,

in press-b). Attendance at Alcoholics Anonymous meetings is usually

advocated and sometimes mandated. Various forms of relapse

prevention counseling commonly are practiced (e.g., Gorski and Miller

1982). None of these components has been shown in controlled trials

to contribute significantly to the improvement of treatment outcomes.

Aggressive confrontational counseling tactics, in fact, appear to be

associated with poorer outcomes (e.g., Miller and Rollnick 1991;

Miller et al., in press) and may be particularly detrimental for

individuals with low self-esteem (Annis and Chan 1983).

Counselor Behaviors

There appear to be large differences in effectiveness among counselors

delivering allegedly similar treatments (e.g., McLellan et al. 1988;

Miller et al. 1980). In all studies to date evaluating counselor style, a

reflective, empathic, listening approach has been predictive of more

favorable alcohol treatment outcomes (e.g., Miller et al. 1980, in press;

Valle 1981). It is conceivable that characteristics of counselor style

account for more variance in treatment retention, compliance, and

outcome than declared therapeutic approach. In studying the

effectiveness of behavioral treatments for drug abuse, therefore, the

173
influence of therapist characteristics and behavior should not be

overlooked.

Client Characteristics

Client characteristics represent another determinant of treatment

outcome (Moos et al. 1990). Reviewers have had little success in

identifying universal prognostic characteristics of individuals in

treatment for alcohol problems (e.g., Gibbs and Flanagan 1977). It is

conceivable, however, that profiles of optimal responder characteristics

could be identified for specific treatment modalities (Miller and Hester

1986b). If such responder profiles are consistent across studies,

criteria can be derived for a priori matching of clients to treatment

approaches. Kadden and colleagues (1989) found that behavioral skills

training was more effective than interactional therapy with alcoholics

higher in psychopathology in general and sociopathy in particular.

Project MATCH, an NIAAA multisite collaborative trial, is comparing

12-step, cognitive-behavioral, and motivational strategies in seeking

differential predictors of response. It is likely that behavioral

treatments are not optimally effective for all drug abusers, but they

may be for definable subgroups. Different approaches may be more

effective for clients with other characteristics.

RECOMMENDATIONS FOR RESEARCH

The accumulated research on treatment for alcohol problems suggests

several general recommendations for future research on treatment

(including behavioral treatment) for drug abuse more generally.

Treatment researchers may be able to avoid some of the same pitfalls

and blind alleys by considering this large existing literature.

1. It would be sensible to adapt and replicate for treatment of other

drug problems those therapeutic modalities (primarily behavioral)

that have been shown to be most effective in treating alcohol

problems. A half century of outcome research points to specific

treatment methods that are more (and less) promising, and this

knowledge can be used to guide future research and practice.

174
2. Paralleling the recommendations of the National Academy of

Sciences (1990) with regard to alcohol problems, drug use and

problems can be understood as lying along a continuum of

severity. Different intervention strategies are likely to be effective

at various points along that continuum. Brief cognitivemotivational interventions may be particularly cost-effective in

addressing the large population of individuals with less severe drug

problems and dependence.

3. The impact of treatment settings should be separated from

therapeutic modalities. The alcoholism literature suggests that

there is little or no overall difference in effectiveness (but

substantial difference in cost) between residential/inpatient

programs and outpatient/community approaches (Miller and Hester

1986c; U.S. Congress 1983). It remains to be determined whether

particular treatment modalities are differentially effective in

alternative treatment settings.

4. Clinical trials and other treatment studies should include measures

of therapist behavior and treatment processes. Attrition from and

effectiveness of treatment in general, and of behavioral modalities

in particular, appear to be impacted substantially by the

characteristics of those who deliver the therapies.

5. Relevant client characteristics also should be assessed so

pretreatment markers of therapeutic response can be identified. In

trials comparing different treatments, tests for interaction effects

with client characteristics should be routinely explored.

6. Studies of behavioral and other treatments will advance knowledge

more effectively when designed to detect the mechanisms of

therapeutic effect. Theory-grounded treatments are hypothesized to

work for particular reasons, and it is worthwhile to test whether

observed relationships between independent and dependent

variables are consistent with these accounts.

7. Treatment research should include procedures to measure the cost

of delivering the services under study. Treatment policy can be

guided by knowledge not only of the relative effectiveness of

alternative strategies, but also of relative cost.

175
8. Given the substantial overlap between alcohol and other drug

abuse in clinical populations, it would be advantageous for clinical

trials in both NIDA and NIAAA to include state-of-the-art outcome

measures for drug use (including alcohol use) in general Alcohol

treatment research to date has been plagued by a lack of

consistency in outcome measures. It would be particularly

beneficial to develop consensual prototypic assessment procedures

to permit comparison of outcomes across studies.

SUMMARY

Behavioral approaches have a strong track record in the treatment of

alcohol problems. They are generally cost-effective (Holder et al.

1991), can be readily combined with and enhance the effectiveness of

pharmacologic interventions (e.g., Azrin et al. 1982), and have been

found to be applicable all along the continuum of problem severity.

Cognitive-behavioral strategies appear to be particularly helpful in

addressing common problems of treatment motivation, retention, and

compliance. There is no reason to expect substantially different

findings when behavioral strategies are applied in the treatment of

other drug problems.

REFERENCES

Annis, H.M., and Chan, D. The differential treatment model: Empirical

evidence from a personality typology of adult offenders. Crim

Justice Behav 10:159-173, 1983.

Azrin, N.H.; Sisson, R.W.; Meyers, R.; and Godley, M. Alcoholism

treatment by disulfiram and community reinforcement therapy.

Behav Res Ther 14:339-348, 1982.

Baekeland, F. Evaluation of treatment methods in chronic alcoholism.

In: Kissin, B., and Begleiter, H., eds. The Biology of Alcoholism.

Vol. 5. New York: Plenum Press, 1977.

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for

alcohol problems: A review. Brit J Addict, in press.

Bowman, K.M., and Jellinek, E.M. Alcohol addiction and its treatment.

Q J Stud Alcohol 2:98-176, 1941.

176
Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; and Wilson, G.T.

Understanding and preventing relapse. Am Psychol 41:765-782,

1986.

Costello, R.M.; Biever, P.; and Baillargeon, J.G. Alcoholism treatment

programming: Historical trends and modern approaches. Alcohol

Clin Exp Res 1:311-318, 1977.

Elkins, R.L. Covert sensitization treatment of alcoholism: Contributions

of successful conditioning to subsequent abstinence maintenance.

Addict Behav 5:67-89, 1980.

Emrick, C.D. A review of psychologically oriented treatment of

alcoholism: I. The use and interrelationships of outcome criteria and

drinking behavior following treatment. Q J Stud Alcohol 35:523-

549, 1974.

Emrick, C.D. A review of psychologically oriented treatment of

alcoholism: II. The relative effectiveness of different treatment

approaches and the effectiveness of treatment versus no treatment.

J Stud Alcohol 36:88-108, 1975.

Fuller, R.K. Antidipsotropic medications. In: Hester, R.K., and Miller,

W.R., eds. Handbook of Alcoholism Treatment Approaches:

Effective Alternatives. New York: Pergamon Press, 1989.

pp. 117-127.

Gibbs, L., and Flanagan, J. Prognostic indicators of alcoholism

treatment outcome. Int J Addict 12:1097-1141, 1977.

Gorski, T.F., and Miller, M. Counseling for Relapse Prevention.

Independence, MO: Herald House-Independence Press, 1982.

Greeley, J., and Westbrook, F. Associative learning, drug use and

addictive behaviour. In: Heather, N.; Miller, W.R.; and Greeley, J.,

eds. Self-Control and the Addictive Behaviours. Sydney: Maxwell

Macmillan Publishing Australia, 1991. pp. 127-150.

Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the

Addictive Behaviours. Sydney: Maxwell Macmillan Publishing

Australia, 1991.

Hester, R.K., and Miller, W.R. Self-control training. In: Hester, R.K.,

and Miller, W.R., eds. Handbook of Alcoholism Treatment

Approaches: Effective Alternatives. New York: Pergamon Press,

1989. pp. 141-149.

Higgins, S.T.; Delaney, D.D.; Budney, A.J.; Bickel, W.K.; Hughes,

J.R.; Foerg, F.; and Fenwick, J.W. A behavioral approach to

achieving initial cocaine abstinence. Am J Psychiatry

148:1218-1224, 1991.

177
Holder, H.; Longabaugh, R.; Miller, W.R.; and Rubonis, A.V. The cost

effectiveness of treatment for alcoholism: A first approximation.

J Stud Alcohol 52:517-540, 1991.

Kadden, R.M.; Cooney, N.L.; Getter, H.; and Litt, M.D. Matching

alcoholics to coping skills or interactional therapies: Posttreatment

results. J Consult Clin Psychol 57:698-704, 1989.

McLellan, A.T.; Woody, G.E.; Luborsky, L; and Goehl, L. Is the

counselor an “active ingredient” in substance abuse rehabilitation?

An examination of treatment success among four counselors. J Nerv

Ment Dis 176:423-430, 1988.

Miller, W.R., ed. The Addictive Behaviors: Treatment of Alcoholism,

Drug Abuse, Smoking, and Obesity. Elmsford, NY: Pergamon Press,

1980.

Miller, W.R. Alcoholism: Toward a better disease model. Psychol

Addict Behav, in press-b.

Miller, W.R. The evolution of treatment for alcohol problems: From

the 1940’s to the 1980’s. In: 40th Anniversary Lecture Series.

Toronto: Addiction Research Foundation, in press-a.

Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhancing motivation

for change in problem drinking: A controlled comparison of two

therapist styles. J Consult Clin Psychol in press.

Miller, W.R., and Dougher, M.J. Covert sensitization: Alternative

treatment procedures for alcoholism. Behav Psychother 17:203-220,

1989.

Miller, W.R., and Hester, R.K. Treating the problem drinker: Modem

approaches. In: Miller, W.R., ed. The Addictive Behaviors:

Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity.

Elmsford, NY: Pergamon Press, 1980. pp. 11-141.

Miller, W.R., and Hester, R.K. The effectiveness of alcoholism

treatment methods: What research reveals. In: Miller, W.R., and

Heather, N., eds. Treating Addictive Behaviors: Processes of

Change. New York: Plenum Press, 1986a. pp. 121-174.

Miller, W.R., and Hester, R.K. Inpatient alcoholism treatment: Who

benefits? Am Psychol 41:794-805, 1986c .

Miller, W.R., and Hester, R.K. Matching problem drinkers with

optimal treatments. In: Miller, W.R., and Heather, N., eds. Treating

Addictive Behaviors: Processes of Change. New York: Plenum

Press, 1986b. pp. 175-203.

178
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing

People To Change Addictive Behavior. New York: Guilford Press,

1991.

Miller, W.R., and Sanchez, V.C. Motivating young adults for treatment

and lifestyle change. In: Howard, G., ed. Issues in Alcohol Use and

Misuse by Young Adults, Notre Dame, IN: University of Notre

Dame Press, in press.

Miller, W.R., and Sovereign, R.G. The check-up: A model for early

intervention in addictive behaviors. In: Addictive Behaviors:

Prevention and Early Intervention. Amsterdam: Swets and

Zeitlinger, 1989. pp. 219-231.

Miller, W.R.; Taylor, C.A.; and West, J.C. Focused versus broad

spectrum behavior therapy for problem drinkers. J Consult Clin

Psychol 48:590-601, 1980.

Monti, P.M.; Abrams, D.B.; Binkoff, J.A.; and Zwick, W.R. Social

skills training and substance abuse. In: Hollin, C.R., and Trower, P.,

eds. Handbook of Social Skills Training. Vol. 2. New York:

Pergamon Press, 1986. pp. 111-142.

Moos, R.H.; Finney, J.W.; and Cronkite, R.C. Alcoholism Treatment:

Context, Process, and Outcome. New York: Oxford University

Press, 1990.

National Academy of Sciences, Institute of Medicine. Broadening the

Base of Treatment for Alcohol Problems. Washington, DC: National

Academy Press, 1990.

O’Farrell, T.J., and Cowles, K.S. Marital and family therapy. In:

Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism

Treatment Approaches: Effective Alternatives. New York: Pergamon

Press, 1989. pp. 117-127.

Orford, J. Excessive Appetites: A Psychological View of Addictions.

New York: John Wiley, 1985.

Peele, S. The Meaning of Addiction: Compulsive Experience and Its

Interpretation. Lexington, MA: Lexington Books, 1985.

Sanchez-Craig, M.; Annis, H.M.; Bomet, A.R.; and MacDonald, K.R.

Random assignment to abstinence and controlled drinking:

Evaluation of a cognitive-behavioural program for problem drinkers.

J Consult Clin Psychol 52:390-403, 1984.

Sisson, R.W., and Azrin, N.H. The community reinforcement approach.

In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism

Treatment Approaches: Effective Alternatives. New York: Pergamon

Press, 1989. pp. 242-258.

179
Stockwell, T., and Town, C. Anxiety and stress management. In:

Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism

Treatment Approaches: Effective Alternatives. New York: Pergamon

Press, 1989. pp. 222-230.

U.S. Congress, Office of Technology Assessment. The Effectiveness

and Costs of Alcoholism Treatment. Washington, DC: U.S. Govt.

Print. Off., 1983.

Valle, S.K. Interpersonal functioning of alcoholism counselors and

treatment outcome. J Stud Alcohol 42:783-790, 1981.

Voegtlin, W.L., and Lemere, F. The treatment of alcohol addiction:

A review. Q J Stud Alcohol 2:717-803, 1941.

Wilkinson, D.A., and LeBreton, S. Early indications of treatment

outcome in multiple drug users. In: Miller, W.R., and Heather, N.,

eds. Treating Addictive Behaviors: Processes of Change. New York:

Plenum Press, 1986. pp. 239-261.

ACKNOWLEDGMENT

Preparation of this chapter was supported in part by grant number

K05-AA09051 from the National Institute on Alcohol Abuse and

Alcoholism.

AUTHOR

William R. Miller, Ph.D.

Professor of Psychology and Psychiatry

Department of Psychology

and

Director

Research Division

Center on Alcoholism, Substance Abuse, and Addictions (CASAA)

The University of New Mexico

Albuquerque, NM 87131-1161

180
Multisystemic Treatment of

Serious Juvenile Offenders:

Implications for the Treatment of

Substance-Abusing Youths

Scott W. Henggeler

INTRODUCTION

This chapter provides an overview of the multisystemic approach to

treating serious antisocial behavior in adolescents and builds a case for

using multisystemic therapy (MST) (Henggeler and Borduin 1990) in

the treatment of substance-abusing adolescents. As such, sections in

the chapter focus on similarities between delinquency and substance

use in their identified correlates, recalcitrance to treatment, and service

delivery issues; results from controlled outcome studies supporting the

effectiveness of MST and future directions in the validation and

diffusion of MST; and an overview of clinical interventions used in

MST.

DELINQUENCY AND SUBSTANCE ABUSE

Research findings within the areas of delinquency and substance abuse

have at least three important commonalities. First, the identified

correlates and risk factors of delinquency and substance abuse are

largely the same. Second, delinquency and substance abuse have

proven to be recalcitrant to treatment, with few controlled studies

demonstrating that any particular treatment is superior to any

alternative treatment or to no treatment. Third, the delivery of mental

health services to juvenile offenders and to substance-abusing

adolescents share several obstacles.

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Indentified Correlate

Reviewers consistently have concluded that criminal activity in

adolescents is associated with important characteristics of the

individual youth, family, peer system, school system, and community

(e.g., Henggeler 1989; Melton and Hargrove, in press; Quay 1987). In

light of the numerous correlates of delinquency, several investigators

have developed multidimensional causal models (for a review, see

Henggeler 1991). In each of these models, factors from several

ecological systems contributed directly or indirectly to delinquency.

For example, Elliott and coworkers (1985) found that delinquency was

predicted directly by previous antisocial behavior and by association

with deviant peers; association with deviant peers was predicted by

difficulties pertaining to the family system and the school system.

Adolescent substance abuse also has been associated with youth

characteristics, family factors, peer factors, and school factors (Schinke

et al. 1991), and investigators have developed multidimensional causal

models examining the relations among these correlates. For example,

Elliott and colleagues (1985) found results similar to those noted above

when predicting substance use. Similarly, Dishion and coworkers

(1988) reported that parental drug use and deviant peer influences

directly predicted youths’ drug use and that parental monitoring

predicted association with deviant peers. Again, factors across several

ecological systems contributed directly or indirectly to substance use

(or abuse).

Recalcitrance to Treatment

The development of effective treatments for delinquency has been

extremely problematic. In the late 1970’s, for example, several

reviewers of treatment outcome studies with delinquents concluded that

“nothing works” (e.g., Romig 1978). More recently, reviewers (e.g.,

Kazdin 1987) suggested that promising new treatment strategies (e.g.,

cognitive behavior therapy, behavioral parent training, and functional

family therapy) have emerged. Although these treatments have been

moderately successful with mild forms of antisocial behavior,

controlled studies have not supported their effectiveness with serious

antisocial behavior (Bank et al. 1991; Guerra and Slaby 1990; Weisz et

al. 1990).

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Likewise, little evidence suggests that any particular treatment of

adolescent substance abuse is more effective than no treatment

(Beschner and Friedman 1985; Martin and Wilkinson 1989; Newcomb

and Bentler 1989; Schinke et al. 1991). Although several large-scale,

uncontrolled studies have documented positive changes on adolescent

substance use variables (e.g., Friedman et al. 1986; Sells and Simpson

1979), the conclusion that treatment produced such changes is

mitigated by design limitations inherent in such studies. Moreover, in

those few studies in which random assignment to treatment conditions

has been used (Lewis et al. 1990; Szapocznik et al. 1986), differential

treatment effects were not observed.

Service System Issues

Difficulties in the development of effective treatments for delinquency

and substance abuse are compounded by several problems in the

delivery of children’s mental health services. First, as numerous

reviewers have noted, children’s mental health services are seriously

fragmented (e.g., Burns and Friedman 1990; Dougherty 1988) and lack

coordination with other key service systems such as juvenile justice

(Tuma 1989). Second, large gaps are evident between service needs

and service system capacities (Burns and Friedman 1990; Tamowski

1991). Third, in spite of the need for services, especially among

disadvantaged youths, a grossly disproportionate amount of revenue is

devoted to the small percentage of youths who receive out-of-home

care (Burns 1991). Fourth, expensive out-of-home treatments might be

justified if they were effective. Inpatient hospitalization and residential

treatment programs, however, have received virtually no support in

controlled clinical trials (U.S. Congress 1991).

In light of extant problems in mental health service delivery, policy

analysts have argued that the various child service systems must

undergo substantive changes, at least three of which are pertinent to

this chapter. First, treatment systems must recognize that children’s

mental health difficulties reflect interactions between individual

characteristics and environmental conditions (see Saxe et al. 1988).

Thus, interventions must strive for ecological validity through treating

youths in the natural environment, rather than placing youths in

artificial settings that are segregated from the community. Second, the

emphasis on passive, office-based services that pervades most

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community mental health centers rarely meets the needs of

disadvantaged families with adolescents who are criminal offenders or

substance abusers (Henggeler and Borduin, in press). Intensive and

persistent outreach efforts are needed to engage such families in

treatment. Third, the development of effective community-based

programs, especially for disadvantaged minority youths, requires the

reallocation of funds that currently are devoted to institutional

treatment (see Burns 1991).

lmplications

Findings in the delinquency and substance abuse literatures are

consistent with the contention that different deviant behaviors share

common influences (e.g., Donovan et al. 1988; Osgood et al. 1988).

Moreover, across the delinquency and substance abuse literatures,

reviewers have concluded that effective treatments should be relatively

complex and should recognize the multiple determinants of deviant

behaviors (e.g., Dishion et al. 1988; Henggeler 1989; Morgan et al.

1989; Mulvey et al. 1990; Rhodes and Jason 1990; Tolan 1990).

Regarding the delivery of such treatments, reviewers (e.g., Burns and

Friedman 1990; U.S. Congress 1991) have concluded consistently that

treatments should be family focused, community based, and costeffective. As described subsequently, MST addresses each of the

aforementioned concerns. More importantly, findings from controlled

clinical trials support the short-term and long-term effectiveness of

MST in treating serious antisocial behavior in adolescents as well as

the significant problems often experienced by their families.

OUTCOME STUDIES EVALUATING MST

Rigorous evaluation has been a cornerstone of the development of

MST. Two substantive evaluations of MST with long-term followups

have been completed recently, and the results from these projects are

presented next. Although most earlier studies did not include such

followup, findings clearly supported the promise of MST, and earlier

studies also are presented briefly. In addition, projects funded by

NIDA and by the National Institute of Mental Health (NIMH)

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currently are evaluating issues of conceptual and practical importance

to the validation of MST, and these projects are described at the

conclusion of this section.

Family Preservation Using MST

In the first evaluation of MST to train therapists from an existing

community mental health center in the MST model, multisystemic

family preservation was examined in the treatment of serious juvenile

offenders (Henggeler et al. 1992). The family preservation model of

service delivery was used because of its theoretical and clinical

compatibility with MST. As discussed more extensively later in the

chapter, family preservation emphasizes services that are home based,

family focused, pragmatic, goal oriented, and time limited (Wells and

Biegel 1991). In addition, therapists are primary service providers (not

brokers of services), with low caseloads and around-the-clock

availability. An important goal of family preservation is to empower

families and to prevent costly out-of-home placements.

Multisystemic family preservation was compared with usual services

provided by the Department of Youth Services in a pretest-posttest

control group design with random assignment to conditions.

Participants were 84 serious juvenile offenders averaging 3.5 prior

arrests and 9.5 weeks of prior incarceration. Fifty-four percent had at

least one arrest for a violent crime. They were judged to be at

imminent risk for out-of-home placement by probation staff.

Assessment batteries were conducted pretreatment and posttreatment,

and followup on recidivism and incarceration was conducted at 59

weeks postreferral.

Results supported the effectiveness of multisystemic family

preservation in reducing the institutionalization of serious juvenile

offenders and in attenuating their criminal activity (figure 1). At

posttest, offenders in the multisystemic condition reported significantly

fewer criminal acts than did their counterparts in the usual services

condition. At followup, offenders in the multisystemic condition had

significantly fewer rearrests and spent significantly fewer days

incarcerated (an average of 73 fewer days). Moreover, MST was

effective at changing key correlates of delinquency. Parent figures and

youths in the multisystemic condition reported increased family

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FIGURE 1. Key outcomes in serious offender project
cohesion and decreased youth aggression with peers as compared with

counterparts in the usual services condition. Analyses also showed that

MST was equally effective with youths and families of divergent

sociocultural backgrounds and with varying strengths and weaknesses.

Finally, multisystemic family preservation was not only more effective

than usual services, it was much less expensive. The average cost per

client for MST was $2,800, which compares favorably with the

average cost of $16,300 per client in the usual services condition

(Melton et al., in press).

The Missouri Delinquency Project

A manuscript is currently in preparation that describes the outcome of

the most extensive evaluation of MST to date (Borduin et al.,

unpublished). Approximately 200 juvenile offenders averaging 4.2

arrests were randomly referred to receive either MST or individual

counseling that focused on personal, family, and academic issues.

Assessment batteries, which included self-report and observational

measures, were completed at pretest and posttest, and recidivism data

were collected at 4 years posttreatment.

Analyses of the 4-year followup data strongly support the long-term

effectiveness of MST. Recidivism rates were 22 percent versus 71

percent for therapy completers (42 percent versus 72 percent for

premature terminators) in the MST and individual counseling

conditions, respectively. Overall, youths who completed MST were

arrested for 29 crimes, compared with 161 crimes for youths who

completed individual counseling. Moreover, crime seriousness ratings

(Hanson et al. 1984) showed that recidivists in the MST condition

perpetrated significantly less serious crimes than did their counterparts.

Analyses of the psychosocial measures also supported the relative

effectiveness of MST. For example, observational measures revealed

significantly improved communication in the families that received

MST compared with families of youths who received individual

counseling.

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Adolescent Sexual Offenders

Borduin and colleagues (1990) published the first controlled evaluation

of any treatment with adolescent sexual offenders. Sixteen juvenile

sexual offenders were assigned randomly to either MST or outpatient

individual counseling. The small sample size precluded analyses of

psychosocial measures, but findings from 3-year recidivism data are

noteworthy. Six of eight juveniles in the individual counseling

condition had been rearrested for at least one sexual offense, in

contrast with only one of the youths in the MST condition. Moreover,

youths in the individual counseling condition also had more arrests for

nonsexual criminal offenses than did youths who received MST.

Although results from this study are certainly not conclusive-due in

part to the small sample size-findings are suggestive and support the

external validity of MST.

Substance Use and Abuse in Serious Juvenile Offenders

Using data from two aforementioned studies (Borduin et al.,

unpublished; Henggeler et al. 1992), Henggeler and colleagues (1991)

evaluated the effects of MST on substance use and abuse in samples of

serious juvenile offenders. Analyses of 4-year recidivism data from

the Missouri Delinquency Project showed that offenders who

participated in MST had significantly fewer arrests for substancerelated crimes than did youths who participated in individual

counseling. Similarly, posttest results in the multisystemic family

preservation study showed that offenders who received MST reported

significantly less substance use than did counterparts who received

usual services. Such findings suggest that MST may be an effective

treatment of adolescent substance abuse, and, as discussed

subsequently, a controlled clinical trial is currently being conducted.

Child Abuse and Neglect

Brunk and colleagues (1987) compared the effectiveness of MST

versus behavioral parent training in the treatment of abusive and

neglectful families, with random assignment of families to treatment

conditions. A strength of this study was that MST was contrasted with

an approach that is considered among the most promising in the child

maltreatment literature. Findings at posttest showed that both

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treatments ameliorated key correlates of child maltreatment, including

parental symptomatology and family stress. In addition, MST was

more effective than behavioral parent training in modifying important

parent-child interactional correlates of maltreatment. In the MST

condition, maltreating parents showed improved effectiveness,

neglectful parents were more responsive, and maltreated children were

more compliant.

Inner-City Juvenile Offenders

The first outcome study done by Henggeler and coworkers (1986)

compared the effectiveness of MST versus standard community

treatment with adolescent criminal offenders. Results showed that

MST produced favorable changes in key correlates of delinquency,

including behavior problems, association with deviant peers, and

parent-adolescent relations. These promising findings set the stage for

the subsequent studies noted above and below.

Current Refinements In the Development and Validation

of MST

MST is being validated further in two separate projects. The first, a

multisite study funded by NIMH, evaluates several important aspects

of the effectiveness and diffusion of multisystemic family preservation

with serious juvenile offenders. Comprehensive followup assessments

of psychosocial functioning are being conducted for the first time to

assess the stability of changes in family relations, peer relations, and

other areas. Issues pertaining to the training of therapists and to the

integrity of treatment delivery are being evaluated. Treatment process

is being studied in an attempt to assess the active ingredients in MST.

Issues pertaining to the diffusion of multisystemic family preservation

to rural sites are being examined.

The second project is evaluating the effectiveness of MST with

substance-abusing juvenile offenders. As noted previously, effective

treatments of adolescent substance abuse have not been validated, and

related results from earlier studies (Henggeler et al. 1991) suggest that

MST may be effective. Particularly interesting aspects of this study

include an examination of treatment process issues, comprehensive

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6-month and 12-month followups, and an evaluation of the effects of

continued therapeutic monitoring after termination from MST.

CLINICAL FEATURES OF MST AND SERVICE DELIVERY

ISSUES

MST is based primarily on a social-ecological model of behavior (e.g.,

Bronfenbrenner 1979). The social-ecological model posits that youths

are embedded in multiple transactional systems (e.g., family, peer, and

school) and that behavior is the product of the reciprocal interplay

between the child and these systems. Such a perspective is consistent

with findings from the aforementioned causal modeling studies of

delinquency and of adolescent substance use.

If a social-ecological model accurately reflects the determinants of

behavior problems, a logical inference is that treatment interventions

should focus on multiple aspects of the youth’s ecology to be effective.

Thus, MST stresses the importance of considering a broad array of

ecological variables when assessing identified problems and

intervening within and between systems as needed on a case-by-case

basis.

MST is unique in its comprehensive conceptualization of clinical

problems, multifaceted nature of interventions, and ecologically valid

location of treatment delivery (i.e., treatment usually is delivered

directly in real-world settings). MST, however, includes few novel

treatment techniques. Therapists delivering MST are trained in the use

of a variety of strategies developed from other theoretical perspectives.

For example, the emphases on family systems and goal-oriented

treatment are similar to those of pragmatic family therapists (e.g.,

Haley 1976; Minuchin 1974), and behavioral (e.g., Blechman 1985)

and cognitive behavioral interventions also are used.

The complexity of MST treatment, however, presents problems in

dissemination and diffusion. Highly circumscribed treatments can be

disseminated with relative ease, but the inherent flexibility of MST

increases the probability of inappropriate treatment. To address this

problem, the South Carolina Department of Mental Health

commissioned the development of an MST Strategic Procedures

190
Manual (Henggeler 1990). Here, the nine central principles of MST

are delineated, and several related issues are discussed. Although still

in the process of field-testing the manual, the authors hope that such a

manual will accurately represent the fundamental nature of MST while

allowing therapists to take advantage of their personal strengths.

Principles of Multisystemic Treatment

1. The primary purpose of assessment is to understand the “fit”

between identified problems and their broader systemic context.

One of the therapist’s initial tasks is to evaluate factors in the

youth’s and family’s social ecology that may be contributing to

identified problems. Such an evaluation is performed through

discussions with various family members and other key informants

(e.g., teachers, peers, and minister). The discussions assess others’

perspectives and provide a mechanism for the therapist’s direct

observations of family transactions. Hypotheses regarding the

determinants of the identified problems are based on the

assessment, and targets for intervention are derived directly from

the hypotheses. As new information is gathered throughout the

course of treatment, hypotheses either will be supported or

disconfirmed. In the case of the latter, new hypotheses (and

interventions) will be formulated. Thus, assessment is ongoing,

and treatment is responsive to feedback and changing hypotheses.

2. Interventions should be present-focused and action oriented,

targeting specific and well-defined problems. Treatment goals are

specified concretely to reduce ambiguity regarding the direction of

treatment and progress toward identified goals. All participants in

treatment are informed of therapeutic goals and of the rationale for

pursuing such goals. Although historical issues interfering with

therapeutic progress may be addressed (e.g., a mother’s sexual

victimization during childhood), the primary thrust of treatment is

on changing the here and now.

3. Interventions should target sequences of behavior within or

between systems. Treatment focuses on changing problematic

relations within systems (e.g., mother-adolescent interactions) or

between systems (e.g., mother-teacher interactions). Although

individual cognitive changes may be needed to facilitate

191
interactional change, the ultimate goal is changing transactions. As

such, the vast majority of interventions address interactions directly

(e.g., family therapy) or indirectly (e.g., teaching the youth how to

resist peer pressure). In the latter case, homework assignments and

followup always attend to the outcome of in vivo practice.

4. Interventions should be developmentally appropriate and should tit

the developmental needs of the youth. Primary developmental

tasks from early adolescence to late adolescence include

emancipation from parents, attaining educational and vocational

direction, and forming positive peer relations. Although

implementation of restrictive parental discipline often is needed

with juvenile offenders, therapists never lose sight of important

developmental tasks, and intervention emphases shift toward these

tasks as behavior problems are reduced. Moreover, the degree of

emphasis on a particular task will vary with the age of the youth.

5. Interventions should be designed to require daily or weekly effort

by family members. Because presenting problems are usually

serious and treatment is time limited, extensive efforts are needed

by all participants to facilitate positive change. Daily homework

assignments serve the dual function of actualizing treatment goals

and of indexing the participants’ efforts. Thus, the rate of positive

change is optimized, and client resistance is identified quickly.

6. Intervention efficacy is evaluated continuously from multiple

perspectives. Positive change is expected each day, and barriers to

obtaining such change are identified as soon as possible.

Continuous evaluation of efficacy provides feedback to the

therapist regarding the accuracy of his or her hypotheses and

interventions. Such feedback enables the therapist to modify

hypotheses and interventions accordingly and to obtain additional

feedback regarding the modifications. When multiple perspectives

of intervention efficacy are obtained, the therapist is less likely to

be fooled by the false reports of respondents.

7. Interventions should be designed to promote treatment

generalization and long-term maintenance of therapeutic change.

Therapists should not enter the system and affect positive outcome

through the force of their personalities and skills because such

192
8.

9.

change will dissipate after the case is terminated. Rather,

interventions should maximize the capacity of family members to

effect changes in their lives. That is, treatment aims to empower

parents and adolescents.

Therapeutic contacts should emphasize the positive. and

interventions should use systemic strengths as levers for change.

Although the inherent nature of the situation (i.e., serious offender

referred from juvenile court) tends to focus attention on the deficits

of the youth and family, considerable attention should be devoted

to identifying the strengths of the youth, the family, and their

social-ecological context. Identifying strengths can bolster the

family members’ confidence in themselves, and such strengths

usually serve as useful vehicles for positive change.

Interventions should be designed to promote responsible behavior

and to decrease irresponsible behavior among family members.

Essentially, parents should behave as parents (e.g., nurturing and

guiding their children), and children should behave as growing

members of the family and community (e.g., helping the family

and building positive extrafamilial relations). Traditional

diagnostic labels are rejected as counterproductive (e.g.,

psychopathic personality), and it is assumed that all therapy

participants have the capacity for loving and constructive behavior.

The Family Preservation Model of Service Delivery

The family preservation model of service delivery has developed

primarily from a social work perspective and has been applied most

often to cases of child abuse and neglect (Nelson et al. 1990).

Nevertheless, the family preservation approach is entirely compatible

with MST. In general, the family preservation model includes direct

provision of services in the home; the provision of ‘total care,’

attending to the broad range of needs presented by multiproblem.

disadvantaged families (versus brokering of services); a team approach

to treatment planning; a low client/therapist ratio; staff availability 24

hours per day, 7 days per week; frequent (often daily) contact with

families; time-limited treatment (usually 2-4 months); provision of

treatment to the system rather than to the individual; treatment success

defined as the responsibility of the treatment team rather than of the

193
client; and expectations for immediate, maximum effort by family

members and staff.

MST is delivered using a family preservation model for several reasons

(Henggeler and Borduin, in press). First, delivery of home-based

treatment helps to overcome resistance, which is a major obstacle to

working with families of serious juvenile offenders. Second,

home-based treatment overcomes logistical problems (e.g., lack of

transportation and adjusting parent’s work schedule). Third, the

therapist’s travel to the family’s home conveys a sense of respect that

promotes a positive therapeutic alliance. Fourth, assessment data are

more likely to be accurate because they are obtained in settings with

relatively high ecological validity. Fifth, interventions are more likely

to be successful when they are implemented in the natural

environment. Sixth, positive change is more likely to be maintained

when the natural environment has been altered to promote such

change.

SUMMARY

MST has proven to significantly decrease rates of antisocial behavior

in serious juvenile offenders. In light of the similarities between the

problems of delinquency and adolescent substance abuse, MST holds

promise as an effective treatment of the latter. Hence, conceptual,

clinical, and service delivery features of MST are presented.

REFERENCES

Bank, L.; Marlowe, J.H.; Reid, J.B.; Patterson, G.R.; and Weinrott,

M.R. A comparative evaluation of parent-training interventions for

families of chronic delinquents. J Abnorm Child Psychol 19:15-33,

1991.

Beschner, G.M., and Friedman, A.S. Treatment of adolescent drug

abusers. Int J Addict 20:971-993, 1985.

Blechman, E.A. Solving Child Behavior Problems at Home and

School. Champaign, IL: Research Press, 1985.

194
Borduin, C.M.; Henggeler, S.W.; Blaske, D.M.; and Stein, R.

Multisystemic treatment of adolescent sexual offenders. Int J

Offender Ther Comp Criminology 35:105-114, 1990.

Borduin, C.M.; Mann, B.J.; Cone, L.T.; Henggeler, S.W.; Fucci, B.R.;

Blaske, D.M.; and Williams, R.A. “Multisystemic Treatment of

Adolescents Referred for Serious and Repeated Antisocial

Behavior.” Unpublished manuscript.

Bronfenbrenner, U. The Ecology of Human Development: Experiments

by Nature and Design. Cambridge, MA: Harvard University Press,

1979.

Brunk, M.; Henggeler, S.W.; and Whelan, J.P. A comparison of

multisystemic therapy and parent training in the brief treatment of

child abuse and neglect. J Consult Clin Psychol 55:311-318, 1987.

Burns, B.J. Mental health service use by adolescents in the 1970s and

1980s. J Am Acad Child Adolesc Psychiatry 30:144-150, 1991.

Burns, B.J., and Friedman, R.M. Examining the research base for child

mental health services and policy. J Ment Health Administration

17:87-97, 1990.

Dishion, T.J.; Patterson, G.R.; and Reid, J.R. Parent and peer factors

associated with sampling in early adolescence: Implications for

treatment. In: Rahdert, E.R., and Grabowski, J., eds. Adolescent

Drug Abuse: Analyses of Treatment Research. National Institute on

Drug Abuse Research Monograph 77. DHHS Pub. No.

(ADM)88-1523. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1988.

Donovan, J.E.; Jessor, R.; and Costa, F.M. Syndrome of problem

behavior in adolescence: A replication. J Consult Clin Psychol

56:762-765, 1988.

Dougherty, D. Children’s mental health problems and services: Current

federal efforts and policy implications. Am Psychol 43:808-812,

1988.

Elliott, D.S.; Huizinga, D.; and Ageton, S.S. Explaining Delinquency

and Drug Use. Beverly Hills, CA: Sage, 1985.

Friedman, A.S.; Glickman, N.W.; and Morrissey, M.R. Prediction to

successful treatment outcome by client characteristics and retention

in treatment in adolescent drug treatment programs: A large-scale

cross validation study. J Drug Educ 16:149-165, 1986.

Guerra, N.G., and Slaby, R.G. Cognitive mediators of aggression in

adolescent offenders: 2. Intervention. Dev Psychol 26:269-277,

1990.

195
Haley, J. Problem Solving Therapy. San Francisco: Jossey-Bass, 1976.

Hanson, C.L.; Henggeler, S.W.; Haefele, W.F.; and Rodick, J.D.

Demographic, individual, and family relationship correlates of

serious and repeated crime among adolescents and their siblings.

J Consult Clin Psychol 52:528-538, 1984.

Henggeler, S.W. Delinquency in Adolescence. Newbury Park, CA:

Sage, 1989.

Henggeler, S.W. Treating Conduct Problems in Children and

Adolescents: An Overview of the Multisystemic Approach. Report to

Division of Children, Adolescents, and Their Families, South

Carolina Department of Mental Health. San Diego: Author, 1990.

Henggeler, S.W. Multidimensional causal models of delinquent

behavior. In: Cohen, R., and Siegel, A., eds. Context and

Development. Hillsdale, NJ: Erlbaum, 1991. pp. 211-231.

Henggeler, S.W., and Borduin, C.M. Family Therapy and Beyond:

A Multisystemic Approach to Treating the Behavior Problems of

Children and Adolescents. Pacific Grove, CA: Brooks/Cole, 1990.

Henggeler, S.W., and Borduin, C.M. Multisystemic treatment of

serious juvenile offenders and their families. In: Schwartz, I.M., ed.

Family- and Home-Based Services. Lincoln, NE: University of

Nebraska Press, in press.

Henggeler, S.W.; Borduin, C.M.; Melton, G.B.; Mann, B.J.; Smith, L.;

Hall, J.A.; Cone, L.; and Fucci, B.R. Effects of multisystemic

therapy on drug use and abuse in serious juvenile offenders: A

progress report from two outcome studies. Fam Dynamics Addict Q

1:40-51, 1991.

Henggeler, S.W.; Melton, G.B.; and Smith, L.A. Family preservation

using multisystemic therapy: An effective alternative to

incarcerating serious juvenile offenders. J Consult Clin Psychol

60:953-961, 1992.

Henggeler, S.W.; Rodick, J.D.; Borduin, C.M.; Hanson, C.L.; Watson,

S.M.; and Urey, J.R. Multisystemic treatment of juvenile offenders:

Effects on adolescent behavior and family interactions. Dev Psychol

22:132-141, 1986.

Kazdin, A.E. Treatment of antisocial behavior in children: Current

status and future directions. Psychol Bull 102:187-203, 1987.

Lewis, R.A.; Piercy, F.; Sprenkle, D.; and Trepper, T. Family-based

interventions and community networking for helping drug abusing

adolescents: The impact of near and far environments. J Adolesc

Res 5:82-95, 1990.

196
Martin, G.W., and Wilkinson, D.A. Methodological issues in the

evaluation of treatment of drug dependence. J Advances Behav Res

Ther 11:133-150. 1989.

Melton, G.B., and Hargrove, D.S. Planning Mental Health Services for

Children and Youth. New York: Guilford, in press.

Melton, G.B.; Henggeler, S.W.; and Smith, L.A. The cost-effectiveness

of home- and community-based services for serious juvenile

offenders. Community Ment Health J, in press.

Minuchin, S. Families and Family Therapy. Cambridge, MA: Harvard

University Press, 1974.

Morgan, P.; Wallack, L.; and Buchanan, D. Waging drug wars:

Prevention strategy or politics as usual. In: Segal, B., ed.

Perspectives on Adolescent Drug Use. New York: Haworth Press,

1989. pp. 99-124.

Mulvey, E.P.; Arthur, M.A.; and Reppucci, N.D. Review of Programs

for the Prevention and Treatment of Delinquency. Office of

Technology Assessment. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1990.

Nelson, K.E.; Landsman, M.J.; and Deutelbaum, W. Three models of

family-centered placement prevention services. Child Welfare

69:3-21, 1990.

Newcomb, M.D., and Bentler, P.M. Substance use and abuse among

children and teenagers. Am Psychol 44:242-248, 1989.

Osgood, D.W.; Johnston, L.D.; O’Malley, P.M.; and Bachman, J.G.

The generality of deviance in late adolescence and early adulthood.

Am Social Rev 53:81-93, 1988.

Quay, H.C., ed. Handbook of Juvenile Delinquency. New York: Wiley,

1987.

Rhodes, J.E., and Jason, L.A. A social stress model of substance abuse.

J Consult Clin Psychol 58:395-401, 1990.

Romig, D. Justice for Our Children. Lexington, MA: Lexington

Books, 1978.

Saxe, L.; Cross, T.; and Silverman, N. Children’s mental health: The

gap between what we know and what we do. Am Psychol

43:800-807, 1988.

Schinke, S.P.; Botvin, G.J.; and Orlandi, M.A. Substance Abuse in

Children and Adolescents: Evaluation and Intervention. Newbury

Park, CA: Sage, 1991.

197
Sells, S.B., and Simpson, D.D. Evaluation of treatment outcome for

youths in the drug abuse reporting program (DARP): A follow-up

study. In: Beschner, G.M., and Friedman, A.A., eds. Youth Drug

Abuse: Problems, Issues, and Treatment. Lexington, MA: Lexington

Books, 1979.

Szapocznik, J.; Kurtines, W.M.; Foote, F.H.; Perez-Vidal, A.; and

Hervis, 0. Conjoint versus one-person family therapy: Further

evidence for the effectiveness of conducting family therapy through

one person with drug-abusing adolescents. J Consult Clin Psychol

54:395-397, 1986.

Tamowski, K.J. Disadvantaged children and families in pediatric

primary care settings: I. Broadening the scope of integrated mental

health service. J Clin Child Psychol 20:351-359, 1991.

Tolan, P. Family therapy, substance abuse, and adolescents: Moving

from isolated cultures to related components. J Fam Psychol

3:454-465, 1990.

Tuma, J.M. Mental health services for children: The state of the art.

Am Psychol 44:188-199, 1989.

U.S. Congress, Office of Technology Assessment. Adolescent Health.

Vol. 2, Background and the Effectiveness of Selected Prevention

and Treatment Services (OTA-H-466). Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1991.

Weisz, J.R.; Walter, B.R.; Weiss, B.; Femandez, G.A.; and Mikow,

V.A. Arrests among emotionally disturbed violent and assaultive

individuals following minimal versus lengthy intervention through

North Carolina’s Willie M Program. J Consult Clin Psychol

58:720-728, 1990.

Wells, K., and Biegel, D.E., eds. Family Preservation Services:

Research and Evaluation. Newbury Park, CA: Sage, 1991.

ACKNOWLEDGMENT

This chapter was prepared with support from National Institute on

Drug Abuse grant DA-08029.

198
AUTHOR

Scott W. Henggeler, Ph.D.

Professor

Department of Psychiatry and Behavioral Sciences

Medical University of South Carolina

171 Ashley Avenue

Charleston, SC 29425-0742

199

Dialectical Behavior Therapy for

Treatment of Borderline

Personality Disorder:

Implications for the Treatment of

Substance Abuse

Marsha M. Linehan

The purpose of this chapter is to describe a behavioral treatment

approach designed specifically for chronically parasuicidal individuals

meeting criteria for borderline personality disorder (BPD). Both the

overlap between substance abuse and BPD as well as common

correlates between the two disorders suggest that Dialectical Behavior

Therapy (DBT), in whole or in part, might be effective as a treatment

for substance abuse in general and for substance abusers who also

meet criteria for BPD in particular. The chapter will first give a brief

overview of the overlap between substance abuse and BPD. Second, it

will describe the central elements of a broad-band, behaviorally based

treatment (DBT) for BPD. Finally, it will briefly describe the

empirical evaluations of the effectiveness of this treatment regime.

BORDERLINE PERSONALITY DISORDER AND SUBSTANCE

ABUSE

Overlap

Impulsiveness in areas that are potentially self-damaging is part of the

criteria for BPD. Substance abuse counts as half of this criterion in

both DSM-III-R (American Psychiatric Association 1987) and DSM-IV

(American Psychiatric Association Task Force on DSM-IV 1991).

Thus, it is not surprising that, compared with individuals with all other

personality disorders (except antisocial disorder) and with psychiatric

patients with no personality disorders, individuals meeting criteria for

BPD score higher on substance abuse scales (Pitts et al. 1985; McCann

201
et al. 1992), more commonly report a history of substance abuse

(Akiskal et al. 1985), and also meet criteria for current substance abuse

(Loranger and Tulis 1985; Zanarini et al. 1989; Dulit et al. 1990;

Koenigsberg et al. 1985). In the study conducted by Zanarini and

colleagues (1989), 84 percent of 50 borderline outpatients had met

criteria for substance abuse/dependence at some point in their lives. In

the study conducted by Dulit and coworkers, 67 percent of BPD

patients met criteria for substance abuse disorder. When substance

abuse was not used as a criteria for BPD, the incidence dropped to 57

percent, still a significant portion of the population. Koenigsberg and

colleagues (1985), reporting on a sample of 2,462 inpatients and

outpatients, found that 21 percent of borderline patients had a primary

Axis I diagnosis of substance abuse. Furthermore, two studies suggest

that BPD individuals are more likely to be polydrug abusers, usually

combining drug and alcohol abuse, than are non-BPD individuals

(Kosten et al. 1989; Nace et al. 1983).

The high incidence of substance abuse among borderline individuals

suggests that, at least some of the time, patterns diagnosed as

indicative of BPD may be better viewed as sequelae of substance

abuse patterns. Indeed, Zweben and Clark (1990-1991) argue that the

overlap between substance abuse and BPD may be a result of

correlates and consequences of substance abuse that masquerade as

BPD symptoms. For example, they note that instability of mood,

inappropriate expression of anger, chaotic interpersonal relationships,

impulsiveness, and persistent feelings of emptiness or boredom (all

criteria for BPD) are characteristic patterns found among serious

substance abusers and may clear up with sufficient abstinence.

However, although the BPD-substance abuse overlap is substantial, not

all substance abusers meet criteria for BPD. In a study of 64 female

psychiatric outpatients meeting criteria for substance abuse, Vaglum

and Vaglum (1985) found that 66 percent also met criteria for BPD.

In a more restricted sample, Nace and colleagues (1983) found that 13

percent of 94 consecutive admissions to an alcohol treatment program

also met criteria for BPD. Tousignant and Kovess (1989) found that

one-third of substance abusers showed a high number of BPD traits.

BPD substance abusers, however, are uniformly more disturbed than

those abusers who do not meet criteria for BPD. Studies have shown

that they are more commonly comorbid for depressive disorders, have

more frequent suicide attempts and accidents, and score higher on

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impulse dyscontrol and antisocial tendencies and lower on reality

testing (Kosten et al. 1989; Inman et al. 1985).

Of particular interest for treatment is the overlap between suicidal

behaviors and both substance abuse and BPD. Suicidal behaviors,

including threats, “gestures,” and suicide attempts, represent one of the

eight (or nine in DSM-IV) criteria for BPD. Parasuicidal behavior (all

acute, intentional, nonfatal, self-injurious behavior, including suicide

attempts) has been called the behavioral specialty of BPD (Gunderson

1984). Although much of this behavior is without lethal intent, the

percentage of those followed after an index treatment who eventually

die by suicide is at least 5 to 10 percent (Stone et al. 1987; Paris et al.

1987; Frances et al. 1986). Similarly, substance abuse is associated

with an increased risk of suicidal behaviors, including both completed

suicides and parasuicide (see Lester 1992). Roy and Linnoila (1986)

estimated that 18 percent of alcoholics subsequently complete suicide.

What is not clear at this point is whether the high rate of suicidal

behaviors among substance abusers is mediated by the concomitant

BPD associated with the substance use disorders.

Achieving treatment success with both BPD and substance abuse has

been notoriously difficult. Although there have been few randomized

controlled trials investigating treatment for BPD, followup studies of

individuals who have received substantial inpatient and outpatient

psychiatric care suggest that current treatments are marginally effective

at best when measured 2 or 3 years following treatment (Perry and

Cooper 1985; Tucker et al. 1987). In contrast, there have been many

controlled trials of treatments for both alcohol and drug abuse.

Although efficacy of treatments has been demonstrated, lasting positive

outcomes have been difficult to achieve (Marlatt and Gordon 1985;

Miller and Rollnick 1991). Substance abuse combined with BPD may

be particularly difficult to treat. Nace and colleagues (1985) reported

that at several years following treatment for substance abuse, these

individuals have more severe problems remaining than do non-BPD

substance abusers.

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OVERVIEW OF DBT

DBT was developed from a combined motivational and capability

deficit model of BPD. The idea was twofold: (1) borderline

individuals lack important interpersonal, self-regulation (including

emotional regulation), and distress tolerance skills, and (2) personal

and environmental factors inhibit the use of behavioral skills that the

individual does have and often reinforce inappropriate borderline

behaviors. The emphasis on capability enhancement is similar to that

in substance abuse treatment models that stress relapse prevention

(Marlatt and Gordon 1985). The emphasis on changing motivational

factors is similar to the motivational interviewing proposed by Miller

and Rollick (1991) and to aversive conditioning models (although DBT

provides a greater emphasis on reinforcement than on punishment).

DBT presumes that attention to both skill acquisition and behavioral

motivation is essential. In developing the treatment, however, it

quickly became apparent that (1) skill training to the extent believed

necessary is extraordinarily difficult, if not impossible, within the

context of a therapy oriented to reducing the motivation to die or act in

a borderline fashion, and (2) sufficient attention to motivational issues

cannot be given in a treatment with the rigorous control of therapy

agenda needed for skill training. From this, the idea developed to split

the therapy into three components, one that focuses primarily on ski

acquisition, one that focuses primarily on motivational issues and skill

strengthening, and one designed explicitly to foster generalization of

skills to the everyday life outside the treatment context. The three

modes in standard outpatient DBT are psychosocial groups (for skill

training), individual psychotherapy (addressing motivational issues and

skill strengthening), and telephone contact with the individual therapist

(addressing generalization). Within each treatment mode, DBT is

characterized by a philosophy of dialectics, a biosocial theoretical

perspective, a hierarchy of treatment targets specific to the mode, and a

set of treatment strategy groups. Space here is too brief to give a

detailed description of each component of the treatment. The

interested reader is referred to the treatment manual and associated

updates (Linehan, 1993a, 1993b).

204
Theoretical Base

As one might suppose from the title of the treatment, DBT flows from

a dialectical philosophical position. “Dialectic” is used here in two

contexts, that of persuasive dialogue and relationship and that of the

fundamental nature of reality. From the point of view of dialogue and

relationship, it refers to change by persuasion and by making use of

the opposition inherent in the therapeutic relationship, rather than by

formal impersonal logic. Thus, unlike analytical thinking, dialectics is

personal, taking into account and affecting the total person, and it does

not seek absolute truth but instead attempts to facilitate the

construction or evolution of truth over time. As a world view,

dialectics convey these coexisting multiple tensions that must be

addressed within the therapeutic relationship, as well as the emphasis

in DBT on (1) a systems perspective (asking always, “What is being

left out of our understanding here?”), (2) searching for synthesis and

balance (to replace the rigid, often extreme, and dichotomous response

characteristics of suicidal and borderline patients), and (3) enhancing

comfort with ambiguity and change, which are viewed as inevitable

aspects of life. The overriding dialectic for the therapist is the

necessity of acceptance of the patient as he or she is within the context

of simultaneously trying to produce change. Treatment strategies are

polarized into those most related to acceptance and those most related

to change, although it is this very polarization that is the mot of many

therapeutic failures. DBT requires that the therapist balance use of

these two types of strategies within each treatment interaction.

The author has proposed elsewhere (Linehan 1993a) that BPD is

primarily a systemic disorder of emotion regulation. Characteristics of

this dysregulation include a high sensitivity to emotional stimuli,

intense response to even low-level stimuli, and a slow return to

baseline combined with an inability to modulate emotional states.

Borderline behavioral patterns either function to remediate negative

emotional arousal directly (a view similar to one that sees substance

abuse as self-medication) or indirectly (e.g., by eliciting help from the

environment) or are inevitable outcomes of unregulated and unstable

emotionality. In short, borderline patterns either are attempts to solve

problem emotions or are problematic sequelae, either of the initial

emotions or of the dysfunctional attempts to reduce emotionality. The

author has further hypothesized that this pattern of dysregulated

205
emotion and behavior is a result of an initial temperamental disposition

to emotionality, and perhaps inadequate modulation, combined with an

invalidating rearing environment. Such an environment is

characterized by a tendency to disregard emotional experiences,

especially negative ones, and oversimplify the ease of solving difficult

problems, and it puts a high value on positive thinking. Although such

attitudes are certainly beneficial for some, if not most, this type of

environment invalidates the experiences of vulnerable individuals and

does not take seriously their communications, especially when such

communications have to do with nonpublic events and with difficulties

in meeting social expectations. Invalidating environments, especially

physically and sexually abusive families, contribute to the development

of emotion dysregulation and fail to teach the child how to label and

regulate arousal, how to tolerate emotional distress, and when to trust

one’s own emotional responses as reflections of valid interpretations of

events. At the adult level, borderline individuals adopt the

characteristics of the invalidating environment. Thus, they tend to

invalidate their own affective experiences, look to others for accurate

reflections of external reality, and oversimplify the ease of solving

life’s problems. This oversimplification leads inevitably to unrealistic

goals, an inability to use reward instead of punishment for small steps

towards final goals, and self-hate following failure to achieve these

goals. The shame reaction, a characteristic response to uncontrollable

and negative emotions among borderline individuals, is a natural result

of a social environment that “shames” those who express emotional

vulnerability. These two polar extremes, vulnerability versus

invalidation, represent the central dialectical dilemma of the borderline

patient and therapist.

Treatment Targets

Treatment targets for individual DBT therapy and for DBT as a whole

are the same and are hierarchically arranged as follows:

1. Reducing high-risk suicidal behaviors (parasuicide and high-risk

suicide ideation and plans);

2. Reducing therapy-interfering behaviors-all responses or behaviors

of both the patient and the therapist that make therapy progress or

continuation difficult (e.g., missing or coming late to sessions,

206
3.

4.

5.

6.

7.

phoning at unreasonable hours, refusing to collaborate or work in

sessions, remaining interpersonally aloof or too clinging,

invalidating the other, and not returning phone calls);

Reducing behavioral patterns serious enough to substantially

interfere with any chance of a reasonable quality of life (serious

substance abuse would qualify here);

Behavioral skill acquisition (skills in emotion regulation,

interpersonal effectiveness, distress tolerance, and selfmanagement, as well as a number of “core” [mindfulness] abilities

to observe, describe, participate spontaneously, be nonjudgmental,

focus awareness, and focus on effectiveness);

Reducing posttraumatic stress responses related to previous

traumatic events;

Increasing self-respect; and

Meeting other goals of the patient.

With respect to each target, the task of the therapist is first (and many

times thereafter) to elicit the patient’s collaboration in working on the

target behavior, then to apply the relevant treatment strategies

described below. Attention to each target within individual therapy,

ordinarily involving direct and focused work on the behaviors relevant

to the target, is jointly determined by the hierarchy list above and by

the behaviors and problems that have surfaced since the last session or

during the current session. Thus, treatment is oriented to current

behaviors. Therapy is somewhat circular in that target focal points

revolve over time.

The hierarchy of targets (i.e., what is attended to) is somewhat

different in group skills training and in phone calls. In skills training,

as one might imagine, skills acquisition is the top priority. The only

behaviors that would take precedence are behaviors that threaten to

destroy skills training (e.g., aggression toward other group members or

not coming to sessions). Behavioral skills are taught in modules

concentrating on mindfulness skills (observation, description and

spontaneous participation, nonjudgmentalness, focused attention, and

207
“doing what works”), interpersonal effectiveness for conflict situations,

emotion regulation, and distress tolerance. During telephone calls,

generalization of skills is the top priority, preceded only by threats to

the patient’s life. Thus, during phone calls the focus is always on,

“What skills could you use here?”

Treatment Strategies

DBT addresses all problematic patient behaviors and therapy situations

in a systematic, problem-solving manner that includes conducting a

collaborative behavioral analysis, formulating hypotheses about

possible variables influencing the problem, generating possible changes

(behavioral solutions), and trying out and evaluating the solutions.

The context for this analysis- and solution-oriented approach is that of

validation of each patient’s experiences, especially as they relate to the

individual’s vulnerabilities and sense of desperation. In standard

outpatient DBT, individual therapy sessions meet weekly for 60-90

minutes. During the first year of therapy, all patients attend the

weekly 2- to 21⁄2-hour weekly skills training class. Phone calls for

extra coaching between sessions are encouraged and are accepted

within the therapist’s personal limits.

There are five strategy groups that are combined to deal with specific

problematic situations. Not all strategies are necessary or appropriate

for a given session; the pertinent combination may change over time,

and the emphasis on particular strategies varies depending on mode of

treatment. These are more fully described in the treatment manual

(Linehan 1993a, 1993b).

Dialectical strategies are woven throughout all treatment interactions

and involve both a focus upon the dialectical issues in the therapistpatient relationship as well as promotion of dialectical thought on the

part of the patient. The primary dialectical strategy is the balanced

therapeutic stance described above. Thus, the constant attention to

combining acceptance with change is the essence of the dialectical

strategy. The goal is to bring out the opposites both in therapy and the

patient’s life and to provide conditions for syntheses. The key idea

guiding the therapist’s behavior is that, for any point, an opposite

position can be held. Thus, synthesis and growth require a continuous

search for what is being left out in both the therapist’s and patient’s

208
current ordering of reality and then assisting the patient to create new

orderings that embrace and include what was previously excluded.

The therapist helps the patient move from “either-or” to “both-and.”

Strategies include extensive use of stories, metaphors, myths, and

paradoxes; the therapeutic use of ambiguity (i.e., removing ambiguity

is not necessarily a goal); drawing of the patient’s attention to the fact

of reality as constant change as well as the nonavoidance of change in

the therapeutic conditions; cognitive challenging and restructuring

techniques; and reinforcement for use of intuitive, nonrational

knowledge bases. Dialectical strategies, especially a dialectical

framework on the part of the therapist, are essential in every

interaction with the patient and also inform the treatment supervision

and staff meetings.

Core strategies consist of the balanced application of validation and

problem-solving. Validation requires the therapist to search for,

recognize, and reflect the current validity, or sensibility, of the

individual’s response. Pointing out how a response was functional in

the past but is not now is invalidating, not validating. Nor is

validating simply building up self-esteem, although cheerleading–

focusing on the strengths of the individual and believing in the

individual no matter what-is an important part of validation. If a

person says that he or she is stupid, saying that the person is smart

invalidates the experience of being stupid. The therapist invalidates

the patient’s comment if he or she interprets it as indicative of the

patient’s experiences in similar relationships in which hostility may

have been the norm, rather than searching openly for his or her own

behavior that might actually communicate anger. The essence of

validation is the communication that a response is understandable in

the current context. At times, it is like searching for a speck of gold

in a cup of sand. Not every part of a response is valid, nor is that

which is invalid ignored. However, enough valid responses (or parts

of responses) can be found that validating is done in every interaction.

Problem-solving strategies are a two-stage process involving, first, an

acceptance of the problem at hand and, second, an attempt to generate,

evaluate, and implement alterative solutions that might have been made

or could be made in the future in similar problematic situations. The

acceptance stage employs both insight and behavioral analysis

strategies; the second stage, targeting change, employs solution

209
analysis, commitment, and orientation to change and treatment plans.

Behavioral analysis requires a very detailed chain analysis of the

events and situational factors leading up to and following the particular

problematic response at hand. Insight strategies, no more different

here than in other treatment approaches, include observing and labeling

patterns of behavior and situational influence over time. The behavior

analysis strategy is repeated for every instance of targeted problem

behaviors until the patient achieves an understanding of the stimulusresponse patterns involved. The second stage requires the generation

of alternate response chains (i.e., adaptive solutions to the problem) as

well as an analysis of the individual’s response capabilities. This

process usually leads into skills training and work on motivation

through attention to reinforcement contingencies, therapeutic exposure

to reduce emotions inhibiting functional behavior, and changing of

cognitions that lead to dysfunctional behaviors.

There are three case management strategies designed to guide each

therapist during interactions with individuals outside the therapy dyad.

The consultation/supervision strategy requires that each DBT therapist

meet regularly with a supervisor or consultation team. DBT is

designed as a treatment of a community by a community. Thus, in

most settings this strategy will dictate a weekly meeting of all

therapists applying DBT. The treatment specifies a number of

guidelines for conducting these meetings. The consultant-to-the-patient

strategy is simple in concept but very hard to carry out. The strategy

is the application of the principle that the DBT therapist teaches

patients how to interact effectively with their environment rather than

teaching the environment how to interact with the patients. As a

general norm, DBT therapists do not intervene to adjust environments

for the sake of the patient, nor does the DBT therapist meet or consult

with other professionals about how to treat the patient unless the

patient has an active part in it. This strategy represents a point of view

that looks at adversity and “bad” treatment of the patient by the

environment (including other professional helpers) as an opportunity

for practice and learning. From another perspective, it views the role

of the therapist as teaching the patient to adjust to the world as it is,

with all its problems and inequities. Patients are dealt with as

responsible parties in their interactions with others. A key aspect of

the strategy, of course, includes a definition of who the therapist is.

For example, on an inpatient unit, the entire staff might be deemed the

210
“therapist.” However, even within the staff, application of the strategy

is possible. It simply requires that each therapeutic agent be

responsible for his or her own behavior and not each other’s Thus, it

is not the job of one therapist to defend another therapist, nor is

treatment consistency particularly valued in DBT. As in the real

world, rules may change depending on who is enforcing them.

Although patients not present are discussed in staff meetings, the goal

is to obtain information, not necessarily to influence or change the

other therapist. The information then is used in working with the

patient. (One can immediately see why that is easy in concept and

difficult in practice! Humility is a requisite for this strategy not to go

astray.)

The exception to the consultant strategy is in the following

circumstance: the patient does not have the requisite capability (or

sometimes willingness) to influence the environment, the immediate

outcome is very important, and the therapist can influence it. In this

instance, the therapist uses the environmental intervention strategies to

effect immediate changes that are both essential and that the patient

cannot yet produce. For example, the therapist will consult with

emergency room staff about medications taken by an uncommunicative

patient who overdosed, send required treatment plans to insurance

companies, and possibly go and pick up a teenager trying to come to a

session whose car breaks down.

In DBT, the therapist balances two communication strategies that

represent rather different interactional styles. The modal style is the

reciprocal strategy that includes responsiveness to the patient’s agenda

and wishes, warmth, and self-disclosure of personal information that

might be useful to the patient as well as immediate reactions to the

patient’s behavior. Reciprocity is balanced by an irreverent

communication style that is characterized by a matter-of-fact attitude.

The therapist takes the patient’s underlying assumptions or unnoticed

implications of the patient’s behavior and maximizes or minimizes

them in either an unemotional or overemotional manner to make a

point the patient might not have considered before. The essence of the

strategy is that it “jumps track,” so to speak, from the patient’s current

pattern of response, thought, or emotion.

211
A set of structural strategies specifies for the therapist how to start

and end therapy, how to set an agenda and organize time during

sessions, and how to terminate DBT. For example, DBT uses a

number of strategies drawn from social psychology to create and

enhance commitment to therapy and to change. There are, as well, a

number of integrative strategies covering crisis management, suicidal

behavior, compliance and relationship issues, medication, and use of

ancillary treatments.

TREATMENT EFFICACY FOR DBT

DBT has been evaluated in a controlled treatment trial comparing DBT

to treatment-as-usual (TAU) in the community (Linehan et al. 1991).

Forty-seven women meeting criteria for BPD with a history of multiple

parasuicides (including one within 8 weeks of referral) were randomly

assigned to the two treatment conditions. Treatment lasted 1 year, and

evaluations were conducted at 4-month intervals during a 1-year

followup. Results indicated that DBT was significantly better than

TAU at reducing parasuicidal behavior (including suicide attempts),

days of inpatient hospitalization, and treatment dropouts. In a

reanalysis of the data, Linehan and Heard (1993) found that the

superiority of DBT could not be accounted for by the simple fact that

subjects assigned to DBT had greater access to psychotherapy or to

telephone contact with their therapist. The original study was

conducted in two somewhat independent waves with approximately

equal numbers of subjects in each. Analyses of the second wave

(Linehan et al. 1992), in which a number of additional outcome

measures were added to the assessment battery, indicated that subjects

assigned to DBT, as compared with those assigned to TAU, also

reported significantly less anger, greater social adjustment (including

better employment performance), better work (in employment, school,

and household roles) performance, and less anxious rumination, and

they were rated by the interviewer as more socially adjusted and as

less severely disturbed on the Global Adjustment Scale. At followup

(Linehan et al., in press), gains were maintained in almost all areas of

therapy improvement. The finding that DBT reduces parasuicide

episodes has been replicated by Barley and colleagues (in press) in an

inpatient sample.

212
REFERENCES

Akiskal, H.S.; Chen, S.E.; Davis, G.C.; Puzantian, V.R.; Kashgarian,

M.; and Bolinger, J.M. Borderline: An adjective in search of a

noun. J Clin Psychiatry 46:41-48, 1985.

American Psychiatric Association. Personality Disorders: Diagnostic

and Statistical Manual of Mental Disorders III-R. Washington, DC:

American Psychiatric Association, 1987.

American Psychiatric Association Task Force on DSM-IV. DSM-IV

Options Book: Work in Progress 9/1/91. Washington, DC:

American Psychiatric Association, 1991.

Barley, W.D.; Buie, S.E.; Peterson, E.W.; Hollingsworth, AS.; Griva,

M.; Hickerson, S.C.; Lawson, J.E.; and Bailey, B.J. The

development of an inpatient cognitive-behavioral treatment program

for borderline personality disorder. J Pers Disord, in press.

Dulit, R.A.; Fyer, M.R.; Haas, G.L.; Sullivan, T.; and Frances, A.J.

Substance use in borderline personality disorder. Am J Psychiatry

147:1002-1007, 1990.

Frances, A.; Fyer, M.; and Clarkin, J.F. Personality and suicide. In:

Mann, J.J., and Stanley, M., eds. Psychobiology of Suicidal

Behavior. New York: Annals of the New York Academy of

Sciences, 1986. pp. 281-293.

Gunderson, J.G. Borderline Personality Disorder. Washington, DC:

American Psychiatric Press, Inc., 1984.

Inman, D.J.; Bascue, L.O.; and Skoloda, T. Identification of borderline

personality disorder among substance abuse inpatients. J Subst

Abuse Treat 2:229-232, 1985.

Koenigsberg, H.; Kaplan, R.; Gilmore, M.; and Cooper, A.E. The

relationship between syndrome and personality disorder in DSM-III:

Experience with 2,462 patients. Am J Psychiatry 142:207-212,

1985.

Kosten, R.A.; Kosten, T.R.; and Rounsaville, B.J. Personality disorders

in opiate addicts show prognostic specificity. J Subst Abuse Treat

6:163-168, 1989.

Lester, D. Alcoholism and drug abuse. In: Maris, R.W.; Berman, A.L.;

Maltsberger, J.T.; and Yufit, R.I., eds. Assessment and Prediction of

Suicide. New York: Guilford, 1992. pp. 321-326.

Linehan, M.M. Cognitive Behavioral Therapy of Borderline

Personality Disorder. New York: Guilford Press, 1993a.

213
Linehan, M.M. The Skills Training Manual for Treating Borderline

Personality Disorder. New York: Guilford Press, 1993b .

Linehan, M.M.; Armstrong, H.E.; Suarez, A.; Allmon, D.; and Heard,

H.L. Cognitive-behavioral treatment of chronically parasuicidal

borderline patients. Arch Gen Psychiatry 48:1060-1064, 1991.

Linehan, M.M., and Heard, H.L. Impact of treatment accessibility on

clinical course of parasuicidal patients: In reply to R.E. Hoffman

[Letter to the editor]. Arch Gen Psychiatry 50:157-158, 1993.

Linehan, M.M.; Heard, H.L.; and Armstrong, H.E. Naturalistic

followup of a behavioral treatment for chronically suicidal

borderline patients. Arch Gen Psychiatry, in press.

Linehan, M.M.; Tutek, D.; and Heard, H.L. Interpersonal and social

treatment outcomes for borderline personality disorder. Poster

presented at the annual meeting of the Association for the

Advancement of Behavior Therapy, Boston, MA, 1992.

Loranger, A.W., and Tulis, E.H. Family history of alcoholism in

borderline personality disorder. Arch Gen Psychiatry 42:153-157,

1985.

Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance

Strategies in the Treatment of Addictive Behaviors. New York:

Guilford Press, 1985.

McCann, J.T.; Flynn, P.M.; and Gersh, D.M. MCMI-II diagnosis of

borderline personality disorder: Base rates versus protypic items.

J Pers Assess 58:105-114, 1992.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing

People To Change Addictive Behavior. New York: Guilford Press,

1991.

Nace, E.P.; Saxon, J.J., Jr.; and Shore, N. A comparison of borderline

and nonborderline alcoholic patients. Arch Gen Psychiatry 40:54-56,

1983.

Nace, E.P.; Saxon, J.J., Jr.; and Shore, N. Borderline personality

disorder and alcoholism treatment: A one-year follow-up study.

J Stud Alcohol 47:196-200, 1985.

Paris, J.; Brown, R.; and Nowlis, D. Long-term follow-up of borderline

patients in a general hospital. Comp Psychiatry 28:530-535, 1987.

214
Perry, J.C., and Cooper, S.H. Psychodynamics, symptoms, and

outcome in borderline and antisocial personality disorders and

bipolar type II affective disorder. In: McGlashan, T.H., ed. The

Borderline: Current Empirical Research. Washington, DC:

American Psychiatric Press, 1985. pp. 19-41.

Pitts, W.M.; Gustin, Q.L.; Mitchell, C.; and Snyder, S. MMPI critical

item characteristics of the DSM-III borderline personality disorder. J

Nerv Ment Dis 173:628-631, 1985.

Roy, A., and Linnoila, M. Alcoholism and suicide. Suicide Life Threat

Behav 16:144-173, 1986.

Stone, M.H.; Stone, D.K.; and Hurt, S.W. Natural history of borderline

patients treated by intensive hospitalization. Psychiatr Clin North

Am 10:185-206, 1987.

Tousignant, M., and Kovess, V. Borderline traits among community

alcoholics and problem-drinkers: Rural-urban differences.

Can J Psychiatry 34:796-799, 1989.

Tucker, L.; Bauer, S.F.; Wagner, S.; Harlam, D.; and Shear, I. Longterm hospital treatment of borderline patients: A descriptive

outcome study. Am J Psychiatry 144:1443-1448, 1987.

Vaglum, S., and Vaglum, P. Borderline and other mental disorders in

alcoholic female psychiatric patients: A case control study.

Psychopathology 18:50-60, 1985.

Zanarini, M.C.; Gunderson, J.G.; and Frankenburg, F.R. Axis I

phenomenology of borderline personality disorder. Comp Psychiatry

30:149-156, 1989.

Zweben, J.E., and Clark, H.W. Unrecognized substance misuse:

Clinical hazards and legal vulnerabilities. Int J Addict

25:1431-1451, 1990-91.

ACKNOWLEDGMENT

This chapter was based on research supported by grant MH34486 from

the National Institute of Mental Health, Bethesda, Maryland.

215
AUTHOR

Marsha M. Linehan, Ph.D.

Department of Psychology

NI-25

University of Washington

Seattle, WA 98195

216
Substance Abuse Research:

Outcome Measurement

Conundrums

Karla Moras

INTRODUCTION

This chapter has two purposes: to identify outcome assessment

problems that arise in treatment studies of substance abuse and to

propose strategies that can address some of the problems. The

outcome assessment problems become particularly evident when the

technology model of psychotherapy research (Carroll and Rounsaville

1990; Docherty 1984) is adopted for treatment studies of substance

abuse. This model, as developed and first implemented in the National

Institute of Mental Health (NIMH) Treatment of Depression

Collaborative Research Program (TDCRP) (Elkin et al. 1985, 1988a .

1988b, 1989), has become the standard in psychotherapy research.

The technology model arose from the application to psychotherapy of

clinical trial methods that are used in psychopharmacology research.

The essence of the technology model is attention to procedures that

ensure a study’s internal validity (Campbell and Stanley 1963) and that

thereby maximize the interpretability of outcome findings in terms of

the efficacy or the comparative efficacy of different psychotherapeutic

interventions for certain types of problems. So, for example, the

treatments studied are specified and standardized in detailed manuals,

and therapists are trained and then monitored throughout the study to

ensure that they conduct the designated treatments in a standard way

(Elkin 1984). In addition, careful attention is given to patient selection

because a primary goal is to generalize the outcome findings to

patients with specific types of problems. Thus, structured diagnostic

interviews often are used, and procedures are implemented to ensure

that the diagnosticians make reliable diagnoses when compared to each

other and to an external (nonstudy) standard.

217
The advantages of the technology model for psychotherapy research

have been reviewed by others (e.g., Carroll and Rounsaville 1990).

Suffice it to say that the field of psychotherapy research developed for

about 30 years before the technology model was applied. For at least

the last 10 of those years, leaders in psychotherapy research were

noting the need for a new paradigm. The call was spurred in part by

the recognition that the results of psychotherapy studies repeatedly led

to the same conclusion: all treatments were equally effective

(improvement was found in about 66 percent of treated patients), and

no treatments were found to have specific effects (Frank 1979).

Furthermore, it was difficult to replicate psychotherapy studies because

the actual conduct of the treatments remained unspecified. Thus,

although the technology model of psychotherapy research as realized in

the NIMH TDCRP has been frequently criticized, particularly initially,

the model has in fact become the standard in the field. In support of

the model, it can be noted that the model is consistent with the logic

of “strong inference” (Platt 1964).

Several characteristics of substance-abusing patients and of substance

abuse treatment practices can lead to uninterpretable outcome findings

when procedures associated with the technology model of

psychotherapy research are either ignored or adopted without

modification for treatment studies of substance abuse.’ In the next

section, features of substance abuse patients and treatment practices

that can create problems for standard psychotherapy outcome

assessment procedures are identified and discussed. The points are

summarized in table 1. Then, strategies are considered to address

some of the problems (summarized in table 2). In the final section,

possible strategies for improving outcome assessment in substances

abuse studies are summarized (table 3).

FEATURES OF SUBSTANCE ABUSE TREATMENT STUDIES

THAT CAN COMPROMISE OUTCOME ASSESSMENT

Co-Presence of Multiple Problems

Substance-abusing patient populations such as cocaine and opiate

abusers tend to have multiple problems (McLellan et al. 1980),

including polysubstance abuse (e.g., alcohol, marijuana, and nicotine)

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TABLE 1. Features of substance abuse treatment that compromise outcome assessment.

Impact on Outcome

Feature Effect Assessment

Patient Variables

Co-Present Multiple Problems Tendency to provide Can't attribute outcome to

multiple interventions treatment of interest

Polysubstance abuse;

Comorbid mood, anxiety, and

personality disorders;

Environmental (e.g., housing,

low income);

Social (legal and criminal);

Interpersonal (e.g., conflictual

High dropout rate

Low followup assessment

rate

Can't generalize outcome findings to

patient population of interest

Can't evaluate enduring effects of

treatment

close relationships, low

social support)

Low Motivation for “Cure”

Seeking a drug holiday,

rather than enduring

change

Episodic Course of Substance Abuse

Poor Education

Frequent Substance Use

High early dropout rate

Substance abuse has an

episodic course

Difficulty reading,

comprehending,and

completing assessment

instruments

Affects phenomenological

experience (including

memory encoding)

Has side effects that

mimic common psychiatric

symptoms

Can't generalize outcome findings to

patient population of interest

Can't attribute outcome to treatment

of interest

Can't necessarily attribute outcome

to treatment of interest

Reduced reliability and validity of

commonly used outcome measures

Reduced reliability and validity of

self-report measures and measures

that rely on self-report such as

DSM-III-R diagnoses

Reduced differential diagnostic

reliability of self-report
TABLE 1. Features of substance abuse treatment that compromise outcome assessment (cont).

Impact on Outcome

Feature Effect Assessment

Patient Variables (cont.)

Self-Reported Drug Use Can Be

Unreliable

Treatment Variables

Urinalysis Results Used

as Treatment Intervention

Participation in 12-Step Programs is

Recommended

Reduced reliability of

intake diagnoses

Urinalysis results are used

as major outcome measure

Can motivate patients to

adulterate urine or fail

to provide urine samples

when using drugs

Some patients attend 12-step

programs while in treatment

study

Poor reliability of self-report

drug use outcome measures

Substance use diagnoses of study

samples are unreliable; generalizability of outcome findings are

uncertain

(See below)

Reduced reliability and validity

of major outcome measure

Can't attribute outcome to treatment

of interest
(Chitwood 1985), comorbid psychiatric disorders (Regier et al. 1990;

Rounsaville et al. 1982, 1991; Weiss et al. 1986), medical problems,

environmental problems (e.g., housing or poverty), social problems

(e.g., legal and criminal cases), and interpersonal problems (lack of

stable family or other sustaining relationships or conflict-laden close

relationships).

Issues for Outcome. The fact that substance-abusing patients often

have multiple problems typically is associated with three events that

compromise outcome measurement: multiple interventions are

provided in studies, a large proportion of patients drop out of treatment

programs, and followup assessment rates tend to be very low. The

impacts of each of the three events on outcome assessment will be

discussed in turn.

Multiple Interventions. The natural clinical impulse to provide

multiple interventions to patients who have multiple problems is

manifested in substance abuse research treatment programs. Thus, for

example, treatment programs like those at the Treatment Research Unit

at the University of Pennsylvania Department of Psychiatry often

provide adjunctive services such as medical interventions, assistance

with obtaining benefits from social service agencies, and

psychopharmacological interventions that are not the treatments being

examined. Furthermore, adjunctive services often are provided on an

as-needed basis.

When standard procedures are not followed for dispensing adjunctive

services and when they are provided based on the needs of individual

patients, the adjunctive interventions are not controlled in a study

design. Some patients receive much more frequent interventions and

more types of interventions that could have therapeutic effects than

other patients do. Thus, when adjunctive interventions are dispensed

in a naturalistic way in substance abuse treatment studies, the outcome

findings cannot be attributed to a specific independent variable (i.e., a

form of treatment that is being studied).

High Dropout Rate. Although little evidence exists of why substance

abuse patients drop out of treatment, high dropout rates are well

documented. For example, in an outpatient treatment study of cocaine

abusers, Kleinman and colleagues (1990) reported that 42 percent of

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148 patients dropped out before the first therapy session and, of those

who remained, only 25 percent stayed for 6 or more sessions. The

high dropout rates probably are related in part to the fact that many

substance abuse patients have multiple problems. In fact, the high

dropout rate is another variable that prompts investigators to provide

multiple interventions to substance abuse patients in treatment outcome

studies: the interventions often are offered to retain patients.

High rates of attrition pose serious problems for outcome assessment

because patients who drop out are generally harder to schedule for

termination assessments than are patients who do not drop out. In

other words, outcome data are more difficult to obtain from dropouts

than from remainers. The difficulty of obtaining outcome data, in

addition to the high dropout rates, leads to another problem: study

findings cannot be generalized to the patient population of interest

because the findings are based on only a small subset of those who

were randomly assigned to treatment (Howard et al. 1990).

Low Followup Rate. Some of the types of problems that co-occur in

substance abuse patients (e.g., social, environmental, and interpersonal

problems) contribute to an unstable lifestyle with many moves,

incarceration, lack of a postal address, and unreliable telephone

numbers. Such variables make it difficult to locate patients for

posttreatment followup assessments that are needed to evaluate longterm treatment outcome.

Low Motivation for Cure

It has been observed that many people who seek treatment for

substance abuse want a period of respite from drug use, a “drug

holiday,” rather than long-term abstinence or cure (e.g., Rounsaville

and Kleber 1985).

Issues for Outcome. The fact that many patients who seek treatment

want a period of remission, not long-term discontinuation of drug

abuse, contributes to the observation that substance abuse tends to have

an episodic course (e.g., Khalsa et al. 1990). Patients seeking only a

drug holiday also probably add to the relatively high early dropout rate

in substance abuse treatment. The effects on outcome assessment of

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both of the preceding behavior patterns of substance-abusing patients

are discussed next.

Episodic Course. The fact that substance abuse can have an episodic

course complicates outcome assessment because remission of

symptoms cannot necessarily be interpreted as a treatment effect;

remission can be a manifestation of the natural course of substance

abuse behavior patterns. Of course, substance abuse is not the only

problem that has an episodic course. Panic disorder is another DSMIII-R (American Psychiatric Association 1987) Axis I diagnosis that

tends to be episodic: the frequency of panic attacks often changes

spontaneously. Episodic disorders require special outcome assessment

strategies to obtain findings that can be reasonably attributed to

treatment interventions.

High Early Dropout Rate. To the extent that many patients drop out

of treatment early because their primary goal is to have a brief respite

from drug abuse and the financial, physical, and interpersonal stresses

it creates, outcome assessment is compromised for reasons that were

previously discussed. In addition, if outcome data on early dropouts

are obtained, self-report might indicate that the patient is improved

(e.g., Mercer and Moras 1992), particularly if the measure is frequency

of drug use. However, interpreting such data as evidence that the

treatment was effective is questionable. A change in frequency of drug

use in a person who was seeking to reduce his or her drug use for a

brief period does not indicate that the treatment was effective from a

public health perspective because neither the person’s willingness to

abuse drugs nor his or her pattern of drug abuse was changed.

Poorly Educated Patients

Many substance-abusing patients are educationally disadvantaged.

Poorly educated individuals can have difficulty reading,

comprehending, and completing common outcome measures. Poor

reading comprehension particularly affects self-report measures. Also,

poor education can lead to impaired verbal comprehension and limited

vocabulary, which affect commonly used interviewer-administered

instruments such as the Structured Clinical Interview for DSM-III-R

(Spitzer et al. 1992).

223
Issues for Outcome. Many of the outcome measures that often are

used in psychotherapy research were not developed for individuals

with low levels of reading comprehension. Thus, some measures are

unlikely to have adequate reliability and validity when used without

modification in substance abuse treatment studies.

Frequent Substance Use

Drugs affect people’s perceptual, memory, and biochemical processes;

they affect phenomenological, cognitive, and somatic experience. The

fact that drugs can have pervasive and marked effects on the

experiential and biochemical systems of the human organism means

that the responses of substance-abusing patients to commonly used

outcome measures (e.g., the Hamilton Rating Scale for Depression,

Hamilton 1960) are likely to be influenced in complicated and, as yet,

unmeasured ways compared to the responses of non-substance-abusing

patients.

Issues for Outcome. The fact that substance-abusing patients use

substances creates the most fundamental problems for outcome

assessment. The problems are of several types.

Confounded Pretreatment Scores on Outcome Measures.

Outcome measurement typically involves pretreatment and

posttreatment administration of the same instruments. Pretreatment to

posttreatment differences are interpreted as treatment effects.

However, the pretreatment responses of substance abuse patients are

necessarily affected by the impact that substances have had on their

most recent perceptual processes and phenomenological and somatic

experience. Moreover, those processes and experiences are patients’

main source of the information required to respond to many outcome

measures, both self-report (e.g., Symptom Checklist-90, Derogatis et al.

1974) and interviewer-administered (e.g., Hamilton Rating Scale for

Depression).

Pretreatment responses to outcome measures are complicated further by

an individual’s recent drug ingestion history, such as how long it has

been since drugs were used before completing the pretreatment

assessment and which drugs were used recently (Weiss et al. 1992).

Furthermore, the effect of an individual’s recent drug history on

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pretreatment assessment measures will differ depending upon the time

period enquired about. For example, no standard exists for the inquiry

for the Hamilton Rating Scale for Depression (Hamilton 1960):

1 month is used in some studies; 1 week is used in others. Thus,

depending upon the relationship between how long it has been since a

person used drugs and the period of time inquired about, a

pretreatment measure could obtain scores that reflect the effects of

drug use, withdrawal from drug use, or symptoms that exist when the

patient is drug free. In general, substance abuse studies do not control

for the effect of the preceding variables on pretreatment scores on

outcome measures.

A third problem is that when outcome is assessed, pretreatment scores

are compared to posttreatment scores. If a person has discontinued or

markedly reduced drug use during treatment, then posttreatment

responses will reflect his or her symptom experience when he or she is

drug free. If the pretreatment assessment did not control for recent

drug ingestion status,the comparison of pretreatment to posttreatment

symptom scores cannot be assumed to be a valid index of treatmentrelated changes because the patient’s pretreatment to posttreatment

self-report will have changed simply because drug effects were

affecting his or her experience and response tendencies at pretreatment

but not at posttreatment.

Symptoms of Drug Use Mimic Some Psychiatric Symptoms.

Drug abuse creates very complicated problems for certain outcome

measures such as DSM-III-R (American Psychiatric Association 1987)

diagnoses (Nathan 1991). For example, many DSM-III-R anxiety and

mood disorders have symptoms that also occur with drug use.

Overlapping symptoms can create insurmountable differential

diagnostic problems because the assignment of some diagnoses (e.g.,

major depression) requires the diagnostician to determine if symptoms

that were present for a diagnostically required length of time were

likely to be due to drug use or not. Such determinations often are

compromised because many substance-abusing patients are unable to

provide the precise timeframes needed to determine if psychiatric

symptoms were occurring during a drug-free period.

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Self-Reported Drug Use Is Unreliable

It is generally observed that substance-abusing patients can be

wittingly unreliable informants about their drug use during treatment as

well as about their pretreatment drug use. Some data suggest that the

degree of unreliability of self-report is related to the specific type of

questions asked (Hser et al. 1992).

Issues for Outcome. Unreliable self-report data about substance use

create obvious problems for outcome assessment because the patient is

typically the principal source of information about his or her drug use.

Furthermore, drug use is a major outcome variable in substance abuse

treatment studies, given that drug abuse is usually viewed as the most

serious problem to be treated from a public health perspective.

Unreliable information at pretreatment compromises the validity of

comparisons between pretreatment and posttreatment indices of drug

use that are the basis of outcome assessment. In addition, of course,

unreliable reports of drug use can lead to unreliable initial diagnoses,

thus compromising the internal validity of an outcome study because

the patients studied might not have had the disorders that they were

determined to have and might have had other disorders that were not

detected.

Urinalysis Results Used as Treatment lnterventlon and as

Outcome Measure

The clinical observation that substance-abusing patients can be

unreliable informants about their substance use has led to the collection

of urine samples to monitor drug use The results of urinalyses also

are often used by drug counselors to discuss unacknowledged drug use.

Moreover, experienced substance abuse counselors strongly believe that

the use of urinalysis results is a necessary component of effective

substance abuse treatment, although no systematically collected

evidence exists to support this belief.

The fact that urinalysis results often are used in substance abuse

treatment can prompt investigators to conclude that urinalysis results

must be used in treatments that are being studied in order to preserve

the generalizability or external validity (Campbell and Stanley 1963) of

226
studies. Urinalysis results also generally are regarded by substance

abuse researchers as the most reliable and valid outcome measure of

substance abuse treatment, given that patient self-report is viewed as

unreliable. Furthermore, the results of urinalyses often are used as an

ongoing, repeated measure of treatment effects during the course of

drug abuse treatment.

Issues for Outcome. A problem is posed for outcome assessment

when urinalysis results are used both as a treatment intervention and as

an outcome measure. A patient’s knowledge that the results of

urinalyses will be provided to his or her therapist can create demand

characteristics for the collection of urine samples that will compromise

the reliability and validity of the data. In other words, the fact that

results of the urine tests will have consequences for patients

(consequences that presumably lead them to give unreliable self-report

information about drug use) can motivate them to adulterate urine

samples or fail to provide samples when required, thereby making the

results either unreliable or unobtainable.

Some support is available for the preceding hypothesis that collecting

urine samples under conditions in which the results have an impact on

patients affects the data obtained. For example, in one opioid

maintenance study in which urinalysis results were not communicated

to therapists and not used in treatment and the patients knew this was

the case, at least 60 to 80 percent of the urinalysis results showed

evidence of drug use, even in high-dose methadone subjects. The

positive urine rates were much higher than generally found in the same

clinic when urine results affected treatment decisions (e.g., take-home

methadone or discharge from treatment) (J. Blaine, personal

communication, March 1992).

Participation in 12-Step Programs Recommended

It is generally believed among experienced substance abuse treatment

personnel and researchers that participation in lay treatment programs

based on the 12-step model, such as Alcoholics Anonymous, is a

necessary adjunct to clinic-based treatment programs. This belief is

firmly held, although no controlled evidence exists to support it

(London 1990). The belief has an impact on outcome assessment in

substance abuse research because patients in research treatment

227
programs often are exhorted to participate in 12-step programs while

they are involved in research treatments.

Issues for Outcome. The issues for outcome are essentially the same

as those previously discussed under the subheading “Multiple

Interventions,” namely: the outcome findings cannot be attributed to

the treatment(s) being studied when other interventions that could

affect outcome are being dispensed in a naturalistic, uncontrolled way.

In substance abuse studies, typically no attempts are made to measure

or control 12-step meeting attendance. Thus, only some patients will

attend 12-step programs, some will attend more meetings than others

will, and patients will attend different 12-step meetings. The last is a

problem because the qualities of meetings held in different places vary

widely, according to people who regularly attend them.

STRATEGIES TO ADDRESS OUTCOME ASSESSMENT

PROBLEMS

Seven features of substance abuse treatment studies that compromise

outcome assessment were identified in the previous section. Some

features are more directly under the control of investigators than others

are and, therefore, have relatively straightforward solutions. For

example, encouraging patients to attend 12-step program meetings

while they are participating in research treatments can be addressed

simply. Investigators can either chose to discontinue the practice and

ask study patients to refrain from attending 12-step meetings while

receiving treatment in the study or include 12-step meetings in a

standard, replicable way in their research treatment programs.

Similarly, for the use of urinalysis results as both a treatment

intervention and an outcome measure, investigators can decide not to

use the results in the study treatments if urinalysis results are to be

used as an outcome measure. The impact of a third feature on

outcome, poorly educated patients, is at least partially under the control

of investigators. Standard self-report outcome measures can be

assessed to determine the reading level required. Instruments can be

modified to match the expected reading level of study samples. In

some cases, investigators might need to exclude commonly used

instruments if modifying them will compromise their purpose.

228
Four other features of substance abuse treatment studies were identified

in the previous section that are not directly under the control of

investigators. All are features of some substance-abusing patients who

present for treatment: multiple problems, low motivation for cure and

the related episodic course of substance abuse, frequent substance

abuse, and unreliable self-report information about drug use. A fifth

major problem, high dropout rate, came up in the discussion of two of

the preceding five features. Strategies for addressing each of the

foregoing features are discussed next. (For summary, see table 2.)

Co-Presence of Multiple Problems

Adopt Assumption That Homogeneous Subsets of Patients Exist

With Etiologically Different Substance Abuse; Test Theoretically

Derived Treatments on the Subsets. The fact that some but not all

drug-abusing patients have multiple problems suggests that substanceabusing patients might be an etiologically heterogeneous group (cf.,

Robins 1990; World Health Organization 1981). For example,

substance abuse in some patients might be a secondary problem, a

correlate of social-environmental problems (such as poverty, poor

educational and career opportunities, or unstable family structure) that

lead to low hope and few aspirations. For such patients, treating only

the substance abuse would be predicted to be ineffective in alleviating

it, particularly in an enduring way. In other patients, substance abuse

might be secondary to some other psychiatric problem such as an

anxiety disorder, chronic depression, or personality disorder. A third

subset of substance-abusing patients might exist whose primary

problem is substance abuse. Such patients might enjoy using

substances or have particular vulnerabilities to addiction and have life

problems that develop secondary to the addictive properties of

substances.

The preceding heterogeneous group hypothesis implies that: (1) not all

substance abuse patients require multiple interventions because not all

have multiple problems, and (2) various subtypes of multiproblem

substance abuse patients exist and the subtypes might respond

optimally to multicomponent treatments that have components

designed specifically for the set of problems that a patient has.

Furthermore, the heterogeneous group hypothesis is consistent with the

229
TABLE 2. Research strategies to improve outcome assessment in substance abuse treatment studies.
TABLE 2. Research strategies to improve outcome assessment in substance abuse treatment studies (cont.).
TABLE 2. Research strategies to improve outcome assessment in substance abuse treatment studies (cont.).
TABLE 2. Research strategies to improve outcome assessment in substance abuse treatment studies (cont.).
TABLE 2. Research strategies to improve outcome assessment in substance abuse treatment studies (cont.).
development of theoretically driven treatments based on etiological

models of different subtypes of substance abuse.

Developing and testing multicomponent treatments that are based on

etiological models of substance abuse subtypes would address the

problems posed to outcome assessment when multiple interventions are

included in substance abuse treatment studies in naturalistic ways. The

research strategy would increase the probability that all interventions

used would be provided in a standard, controlled way because the

interventions would be theoretically driven. Also, the strategy would

lead to examination of the assumption that effective substance abuse

treatment requires multiple interventions.

Low Motivation for Cure

Exclude Patients Who Are Seeking Drug Holidays. If a goal of

research is to identify and develop treatments that have lasting effects

on substance abuse, then the treatments should be tested with patients

who also are seeking that result. In other words, a way to deal with

the problems posed by low motivation for cure to obtaining

meaningful outcome data is to select patients who are more similar to

those who commonly enter psychotherapy studies (i.e., patients who

seek treatment because they want permanent remission of their

presenting problems).

The preceding strategy requires the development of selection

procedures that can distinguish patients seeking cure from those

seeking respite. The distinction might be relatively easy to make

based on self-report if no unwanted consequence occurs to patients

who admit to seeking only temporary abstinence or reduction of drug

use. One way to enhance the probability that patients will reliably

state their treatment goal is to provide something for both types of

patients (cure and respite) in a study design. For example, patients

who mainly want help reducing their drug use would be offered a

short-term drug-use reduction and detoxification program.2 Those

seeking cure would be assigned to the treatments being studied.

235
Episodic Nature of Drug Abuse

Obtain Baseline Measures of the Pretreatment Substance Use

Patterns for >2 Years Preceding Treatment. Use the Data to

Compare With >2- Year Followup Assessments. Although episodic

drug use patterns might be most parsimoniously explained in some

cases as reflecting a desire for drug holidays rather than cure, episodic

patterns also might have other causes. Thus, a useful first step toward

improving the validity of outcome findings with substance abuse

disorders would be to do retrospective and prospective descriptive

studies designed to identify common patterns associated with the abuse

of different substances. The conduct of such studies would both

contribute to the development of methods to obtain drug use pattern

information and identify common patterns that treatments need to

affect.3

If data indicate that substance abuse (or certain types of substance

abuse) is typically an episodic disorder, valid outcome assessment

would require baseline drug use pattern data pretreatment and followup

pattern data posttreatment. Because many patients who seek treatment

have a long history of drug use (Anthony and Helzer 1990;

Rounsaville et al. 1982), baseline data should be obtained for at least 2

years pretreatment, and followup data should be obtained for a

comparable period. Procedures need to be developed to compare

pretreatment and posttreatment substance use pattern data. For

example, retrospective data could be obtained by month using time-line

follow-back methods (Sobell et al. 1980) for the 2 years that preceded

treatment. Several drug use indices could be obtained this way, such

as number of months using per year, average frequency of drug use for

highest and lowest month/year, average number of different drugs used

for highest and lowest month/year, and average amount of money

spent on drugs for the highest and lowest month/year. These indices

then could be compared to similar data for a 2-year posttreatment

followup period.

If the type of substance abuse to be studied generally has an episodic

rather than stable course, pattern-of-use data pretreatment and

posttreatment must be obtained to assess treatment efficacy.

Unfortunately, a limitation is that the collection of the type and amount

of data needed in a reliable way can affect the patterns that are being

236
measured. In other words, if close self-monitoring is fostered by

needed data collection, behavior can be affected. A second potential

problem is the difftculty of obtaining the needed followup data for 2

entire years. The latter problem can be addressed by providing a

variety of highly valued incentives for participating in needed

assessments (such as child care coupons, food coupons, transportation

coupons, or payment) and enlisting patients’ social networks to help

locate them.

Frequent Substance Abuse

Limit Symptom-Related Outcome Assessment to Measures That

Are Not Affected by the Type of Drug Use Being Studied. This

recommendation requires careful consideration of the probable impact

of pretreatment substance abuse on the data obtained with each

outcome measure of interest. Measures that will be affected by the

type of drugs used or the length of time that substances were abused

before the pretreatment assessment should be excluded or modified.

For example, if the substance abuse to be treated is cocaine, it might

not be possible to reliably diagnose major depression at pretreatment

unless patients are required to meet an abstinence criterion before the

diagnostic interview (Nathan 1991; Weiss et al. 1992). The diagnosis

then should be excluded from a pretreatment structured diagnostic

interview.

Control for Effect of Recent Drug ingestion on Pretreatment

Measures. The effect of drug use on pretreatment outcome measures

that it will affect should be controlled. One way to do this is to obtain

ratings on symptom measures like the Hamilton scales (Hamilton

1960) for periods when the patient was drug free and unlikely to be

experiencing withdrawal effects. Thus, for example, the Hamilton

inquiry would cover the week preceding the Hamilton interview, and

procedures would be used to ensure that the patient was drug free and

not in withdrawal during that week.

Possible procedures to control for drug use in the week preceding

pretreatment assessments would be to obtain pretreatment ratings on

outcome measures only after a patient had successfully completed a 7-

day abstinence program in which urine samples were obtained that

documented drug-free status during that period. Limitations of the

237
procedure are that the abstinence intervention itself might influence a

patient’s symptom experience during that week, and 1 week is unlikely

to provide a reliable index of a person’s symptom status. An

alternative strategy would be to eliminate pretreatment measures that

will be affected by acute drug ingestion history, acknowledging that

valid scores on them cannot be obtained without introducing a drug

use control procedure which, itself, is likely to affect the validity of the

data (i.e., if the pretreatment data are to be interpreted as indicating

patients’ “natural” and drug-free status on the variables measured).

Reduce Reliance on Measures That Are Based Primarily on SelfReport When Self-Report Is Likely To Be Affected by Drug

Ingestion Status. A third strategy is simply to eliminate pretreatment

assessment on measures such as the Hamilton scales and the SCL-90

(Derogatis et al. 1974) that are designed to assess symptoms likely to

be affected by recent drug ingestion. Resources then could be

redirected toward finding meaningful measures that would not be

invalidated by recent drug use status.

Self-Reported Drug Use Can Be Unreliable

Two reasons are probably the primary contributors to unreliable selfreported drug use: the wish to avoid negative anticipated

consequences of honesty (e.g., the fear that desired benefits will be

withheld if one reveals the truth) and poor or inaccurate memory for

required information. The two reasons require different research

strategies.

Reduce Negative Consequences of Admitting to Drug Abuse.

The assumption behind this recommendation is that in some patients,

at least to some extent, the unreliability of self-reported drug use is

motivated and therefore under the control of the respondent.

Generally, motivated unreliable self-report is believed to result in

underreporting either the amount or number of types of drugs abused.

To the extent that the wish to avoid an anticipated negative event

prompts unreliable self-reported drug use, procedures that reassure

patients that the consequences they fear will not occur can reduce the

problem. The development of procedures requires knowledge of the

feared consequences.

238
A useful contribution to research in substance abuse would be to

systematically obtain patients’ perspectives on feared and wished-for

consequences that can prompt them to either underreport or overreport

drug use. This information is needed to determine what, if any,

reassurances might be provided to offset common reasons for

motivated unreliable self-reported drug abuse. However, such studies

could lead to the conclusion that the preceding strategy is not feasible

because needed reassurances cannot reasonably be provided.

Develop Measures of Drug Use That Do Not Rely on Self-Report.

To the extent that self-reported drug abuse is unreliable because

individuals often do not have mnemonic access to accurate

information, other methods to obtain the information are needed if the

data are regarded as critical to assessment of a treatment’s efficacy.

For example, some individuals who frequently abuse more than one

drug seem unable to report accurately on the frequency, amount,

periods of time, and so on. If self-report generally cannot provide

needed information reliably, alternative sources and methods need to

be used such as objective (public records) or observational data.

Use Baseline Daily Self-Monitoring To Obtain Drug Use Data.

If the desired information cannot reasonably be obtained by methods

other than self-report, one strategy is to provide patients with daily

self-monitoring forms during a baseline pretreatment assessment phase.

During this time, patients would be asked to keep forms with them to

be completed daily, perhaps several times a day. For example, cards

that fit into shirt pockets or wallets have been used in alcohol abuse

studies to facilitate accurate recording of the number of drinks and

drinking episodes. To help ensure that patients remember to record,

frequent telephone check-ins or clinic visits (e.g., every 3 days) can be

used to review records and to prompt short-term memory when data

are missing.

Accept Unreliability of Self-Reported Drug Abuse: Do Not Use

Such Measures as Primary Outcome Indices. This

recommendation is self-explanatory and does not require elaboration.

239
High Dropout Rate

Procedures discussed in prior sections (e.g., selecting patients who are

motivated for cure and selecting subtypes of substance abuse patients

who are offered treatments that are specifically designed for the set of

problems with which they present for treatment) might help lower

dropout rates in substance abuse treatment studies. However, because

attrition is a major handicap to obtaining interpretable treatment

outcome findings, the use of procedures that directly address the

problem also is indicated.

A recommended strategy is to aggressively attempt to locate and obtain

outcome data from patients who drop out rather than to include

retention incentives such as additional services in the treatment

program. The rationale for focusing resources on getting outcome data

from dropouts rather than trying to induce retention is twofold. First,

techniques to induce retention undermine the internal validity of a

study that is designed to evaluate treatment efficacy. Secondly,

attrition rates are an excellent outcome measure as long as outcome

data are obtained from dropouts at the time they leave a study.

Regarding the latter point, for example, if dropout is due to patients’

perceived lack of benefit or the unacceptability of a treatment

approach, attrition rates indicate the proportion of patients for whom a

treatment is unlikely to be effective. Alternatively, if dropout is

mainly due to early recovery (“early” in terms of the anticipated length

of treatment required for optimal effects), attrition rates actually would

enhance efficacy evidence for the treatment being studied.

Incentives for Participating in Assessments After Dropout.

Research experience generally indicates that financial incentives are

effective in increasing the proportion of dropout patients from whom

outcome data can be obtained. Payments are usually based on

consideration of the inconvenience associated with an assessment (e.g.,

difficulty of transportation to the site, including parking difficulty and

costs; child care costs and arrangements; and the amount of time

required to complete the assessment). Fees should be large enough to

defray costs to the patient that are associated with the assessment,

provide compensation for time spent, and provide additional incentive

so that the patient is likely to perceive a personal advantage from

cooperating.

240
Concerns are sometimes raised about using money as an incentive for

substance abuse patients because it can be used to buy drugs and cash

might help create an overwhelming impulse to get high. Alternative

incentives can be used such as coupons for daycare, food, restaurants,

and transportation. Dropout outcome data are so important to

obtaining interpretable results from a treatment study that generous

incentives, whatever their nature, are indicated.

Use Assessments That Do Not Require the Patient To Travel To

Complete Them. A second approach to increasing the proportion of

dropout patients from whom outcome data are obtained is to use

telephone interviews. Many observer-rated outcome measures can be

obtained by telephone. However, some measures or some parts of

measures (e.g., Hamilton scales) use observations made in face-to-face

interviews. Items that require direct observation can be excluded from

both pretreatment and outcome data analyses if an instrument includes

only a few such measures.

Dropouts also can complete self-report questionnaires by mall.

Payment or other incentives can be provided upon receipt of completed

questionnaires. Incomplete responses to returned questionnaires can be

inquired about in telephone interviews. Finally, self-report instruments

can be administered by telephone, although such a procedural

modification should be reported in publications.

SUMMARY: PROCEDURAL RECOMMENDATIONS TO

ENHANCEOUTCOMEASSESSMENTINSUBSTANCEABUSE

TREATMENT STUDIES

Table 3 summarizes the main recommendations that were made in this

chapter to eliminate or reduce outcome assessment problems associated

with substance abuse treatment research when the primary goal is to

obtain interpretable efficacy or comparative efficacy data. Substance

abuse treatment research was reviewed in this chapter from the

perspective of the technology model of psychotherapy research. The

main overall conclusion is that substance-abusing patients pose unique

problems for treatment outcome research, most notably: symptoms of

substance use that mimic psychiatric symptoms, low motivation for

cure, and a tendency to drop out of treatment at high rates. These and

241
TABLE 3. Summary: Procedural recommendations for substance abuse treatment outcome studies.
TABLE 3. Summary: Procedural recommendations for substance abuse treatment outcome studies (cont.).
related features require thoughtful modification of well-established

procedures that are used in randomized clinical trial outcome research

on psychiatric disorders in adults,

NOTES

1. The discussion is focused on features of substance abuse research

that are generally true but not always true because, for example,

characteristics of substance-abusing patient samples can differ

depending upon socioeconomic status.

2. The cost-effectiveness and efficiency of different detoxification

programs also could be examined by such a design.

3. Furthermore, descriptive data of this type can be usefully

incorporated into treatments as an informational component. An

example of this is information on the physiology of symptoms of

panic that is used in cognitive behavioral treatments for panic

disorder (Moras et al. 1990). Such information can provide

nonspecific benefit to patients and increase therapists’ potential

influence because their perceived knowledgeableness will be

increased.

REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual

of Mental Disorders. 3d ed. rev. Washington, DC: American

Psychiatric Association, 1987.

Anthony, J.C., and Helzer, J.E. Syndromes of drug abuse and

dependence. In: Robins, L.N., and Regier, D.A., eds. Psychiatric

Disorders in America: The Epidemiological Catchment Area Study.

New York: Free Press, 1990. pp. 116-154.

Campbell, D.T., and Stanley, J.C. Experimental and QuasiExperimental Designs for Research. Chicago: Rand McNally, 1963.

244
Carroll, K., and Rounsaville, B. Can a technology model of

psychotherapy research be applied to cocaine abuse treatment? In:

Onken, L.S., and Blaine, J.D., eds. Psychotherapy and Counseling

in the Treatment of Drug Abuse. National Institute on Drug Abuse

Research Monograph 104. DHHS Pub. No. (ADM)90-1172.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990.

pp. 91-104.

Chitwood, D.D. Patterns and consequences of cocaine use. In: Kozel,

N.J., and Adams, E.H., eds. Cocaine Use in America:

Epidemiologic and Clinical Perspectives. National Institute on Drug

Abuse Research Monograph 61. DHHS Pub. No. (ADM)87-1414.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.

pp. 111-129.

Derogatis, L.; Lipman, R.; Rickels, K.; Uhlenhuth, E.H.; and Covi, L.

The Hopkins Symptom Checklist (HSCL). In: Pichot, P., ed.

Psychological Measurements in Psychopharmacology. Basel,

Switzerland: S. Karger, 1974. pp. 79-110.

Docherty, J.P. Implications of the technological model of

psychotherapy. In: Williams, J.B.W., and Spitzer, R.L., eds.

Psychotherapy Research: Where Are We and Where Should We Go?

New York: The Guilford Press, 1984. pp. 139-149.

Elkin, I. Specification of the technique variable in the NIMH

Treatment of Depression Collaborative Research Program. In:

Williams, J.B.W., and Spitzer, R.L., eds. Psychotherapy Research:

Where Are We and Where Should We Go? New York: The Guilford

Press, 1984. pp. 150-159.

Elkin, I.; Parloff, M.B.; Hadley, S.W.; and Autry, J.H. NIMH

treatment of depression collaborative research program: Background

and research plan. Arch Gen Psychiatry 42:305-316, 1985.

Elkin, I.; Pilkonis, P.A.; Docherty, J.P.; and Sotsky, S.M. Conceptual

and methodological issues in comparative studies of psychotherapy

and pharmacotherapy: I. Active ingredients and mechanisms of

change. Am J Psychiatry 145:909-917, 1988a.

Elkin, I.; Pilkonis, P.A.; Docherty, J.P.; and Sotsky, S.M. Conceptual

and methodological issues in comparative studies of psychotherapy

and pharmacotherapy: I. Nature and timing of treatment effects.

Am J Psychiatry 145:1070-1076, 1988b.

245
Elkin, I.; Shea, T.M.; Watkins, J.T.; Imber, S.D.; Sotsky, S.M.;

Collins, J.F.; Glass, D.R.; Pilkonis, P.A.; Leber, W.R.; Docherty,

J.P; Fiester, S.J.; and Parloff, M.B. National Institute of Mental

Health Treatment of Depression Collaborative Research Program:

General effectiveness of treatments. Arch Gen Psychiatry 46:971-

982, 1989.

Frank, J.D. The present status of outcome studies. J Consult Clin

Psychol 47:310-316, 1979.

Hamilton, K.I. A rating scale for depression. J Neurol Neurosurg

Psychiatry 23:56-62, 1960.

Howard, K.I.; Cox, W.M.; and Saunders, S.M. Attrition in substance

abuse comparative treatment research: The illusion of randomization. In: Onken, L.S., and Blaine, J.D., eds. Psychotherapy and

Counseling in the Treatment of Drug Abuse. National Institute on

Drug Abuse Research Monograph 104. DHHS Pub. No. (ADM)90-

1172. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990.

pp. 66-79.

Hser, Y.-I.; Anglin, M.D.; and Chou, C.-P. Reliability of retrospective

self-report by narcotics addicts. Psychol Assess 4(2):207-213, 1992.

Khalsa, H.K.; Anglin, M.D.; and Paredes, A. Pm-treatment natural

history of cocaine addiction. In: Harris, L.S., ed. Problems of Drug

Dependence: Proceedings of the 52nd Annual Scientific Meeting,

The Committee on Problems of Drug Dependence, Inc. National

Institute on Drug Abuse Research Monograph 105. DHHS Pub. No.

(ADM)91-1753. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1990. pp. 495-500.

Kleinman, P.H.; Woody, G.E.; Todd, T.C.; Milhnan, R.B.; Kang, S.;

Kemp, J.; and Lipton, D.S. Crack and cocaine abusers in outpatient

psychotherapy. In: Onken, L.S., and Blaine, J.D., eds.

Psychotherapy and Counseling in the Treatment of Drug Abuse.

National Institute on Drug Abuse Research Monograph 104. DHHS

Pub. No. (ADM)90-1172. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1990. pp. 24-35.

London, P. Research priorities for psychotherapy and counseling in the

treatment of drug abuse: The psychotherapy research perspective.

In: Onken, L.S., and Blaine, J.D., eds. Psychotherapy and

Counseling in the Treatment of Drug Abuse. National Institute on

Drug Abuse Research Monograph 104. DHHS Pub. No. (ADM)90-

1172. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off,, 1990.

pp. 121-127.

246
McLellan, R.; Luborsky, L.; Woody, G.; and O’Brien, C. An improved

diagnostic evaluation instrument for substance abuse patients: The

Addiction Severity Index. J Nerv Ment Dis 168:26-33, 1980.

Mercer, D., and Moras, K. “Cocaine Patients’ Reasons for Dropping

Out of Treatment.” Paper presented at the Conference of the Society

for Psychotherapy Research, Berkeley, CA, June 1992.

Moras, K.; Craske, M.G.; and Barlow, D.H. Behavioral and cognitive

therapies for panic disorder. In: Noyes, R.; Roth, M.; and Burrows,

G.D., eds. Handbook of Anxiety. Vol. IV. New York: Elsevier,

1990. pp. 311-325.

Nathan, P.E. Substance use disorders in the DSM-IV. J Abnorm

Psychol 100:356-361, 1991.

Platt, J.R. Strong inference: Certain systematic methods of scientific

thinking may produce much more rapid progress than others.

Science 146(3642):347-353, 1964.

Regier, D.A.; Farmer, M.E.; Rae, D.S.; Locke, B.Z.; Keith, S.J.; Judd,

L.L.; and Goodwin, F.K. Comorbidity of mental disorders with

alcohol and other drug abuse: Results from the epidemiologic

catchment area (ECA) study. JAMA 264(19):2511-2518, 1990.

Robins, L. Assessing substance abuse and other psychiatric disorders:

History of problems, state of affairs. In: Harris, L.S., ed. Problems

of Drug Dependence, 1990: Proceedings of the 52nd Annual

Scientific Meeting, The Committee on Problems of Drug

Dependence, Inc. National Institute on Drug Abuse Research

Monograph 105. DHHS Pub. No. (ADM)91-1753. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1990. pp. 203-212.

Rounsaville, B.J.; Anton, S.F.; Carroll, K.; Budde, D.; Prusoff, B.A.;

and Gawin, F. Psychiatric diagnoses of treatment-seeking cocaine

abusers. Arch Gen Psychiatry 48:43-51, 1991.

Rounsaville, B.J., and Kleber, H.D. Psychotherapy/counseling for

opiate addicts: Strategies for use in different treatment settings.

Int J Addict 20:869-896, 1985.

Rounsaville, B.J.; Weissman, M.M.; Kleber, H.; and Wilber, C. The

heterogeneity of psychiatric diagnosis in treated opiate addicts. Arch

Gen Psychiatry 39:161-166, 1982.

Sobell, M.B.; Maisto, S.A.; Sobell, L.C.; Cooper, M.; Cooper, T.; and

Sanders, B. Developing a prototype for evaluation alcohol treatment

effectiveness. In: Sobell, L.C.; Sobell, M.B.; and Word, E., eds.

Evaluating Alcohol and Drug Abuse Treatment Efectiveness:

Recent Advances. New York: Pergamon, 1980. pp. 129-150.

247
Spitzer, R.L.; Williams, J.B.W.; Gibbon, M.; and First, M.B. The

Structured Clinical Interview for DSM-III-R (SCID): I. History,

rationale, and description. Arch Gen Psychiatry 49:624-629, 1992.

Weiss, R.D.; Mirin, S.M.; and Griffin, M.L. Methodological

considerations in the diagnosis of co-existing psychiatric disorders

in substance abusers. Br J Addict 87:179-187, 1992.

Weiss, R.D.; Mirin, S.M.; Michael, J.L.; and Sollogub, A.C.

Psychopathology in chronic cocaine abusers. Am J Drug Alcohol

Abuse 12: 17-29, 1986.

World Health Organization. Memorandum: Nomenclature and

classification of drug and alcohol-related problems. Bull World

Health Organ 59:225-242, 1981.

ACKNOWLEDGMENTS

Preparation of this manuscript was supported by an NIMH Clinical

Research Center grant (MH 45178) and a NIDA Cooperative

Agreement grant (UO1 DA 07090-01) to Paul Crits-Christoph.

AUTHOR

Karla Moras, Ph.D.

Clinical Research Center for the Study of Psychotherapy

and

Department of Psychiatry

University of Pennsylvania

Room 701

3600 Market Street

Philadelphia, PA 19104-2648

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Between-Group Therapy

Outcome Research: Design and

Methodology

T.D. Borkovec

INTRODUCTION

In the simplest case, the fundamental goal of any between-group

experimental design and its associated methodology is to hold all

factors constant other than the one variable about which

cause-and-effect conclusions are to be drawn. Any differences

observed between comparison conditions representing the manipulation

of that variable cannot be due to the ways in which the experimental

conditions are the same, but only to the ways in which they are

different. Each of the known and unknown ways in which conditions

do, in fact, differ represents a rival hypothesis that could just as likely

explain any observed difference. The fewer rivals that exist (i.e., the

fewer ways in which the conditions differ), the more confident

researchers can be in concluding that the specific difference among the

conditions that were remanipulated experimentally actually caused the

difference between conditions in measured outcome. Random

assignment is the method for increasing the likelihood that the

characteristics of the subject sample are evenly distributed and, thus,

held constant over conditions. Standardization of procedures across all

subjects and the matching of treatment and control conditions on all

procedures except for the crucial manipulation are ways of holding

constant aspects of the environment and the experience of the subjects

in that environment. The purpose of this chapter is to review how

these general methodological guidelines specifically apply to the case

of between-group therapy outcome research and to suggest a general

context in which such research might be considered most usefully.

The goal of therapy outcome research often is thought to be the

demonstration of the efficacy of a therapy technique. Although the

ultimate goal of therapy research is the development and evaluation of

increasingly effective methods of therapy, the position taken here is

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that primary focus on the issue of efficacy in any study is the wrong

approach, short-sighted in its intention and unanswerable in its

customary form. Research that merely aims to show that a method is

effective is, at best, only the starting point of a program of research

and, by itself, is extremely limited in usefulness at both the applied

and the theoretical levels, no matter what types of designs are

employed. Rather, the more heuristic approach is to focus in any

outcome study on the experimental elucidation of the processes by

which a therapy has causative effects on a problem or elucidation of

the nature of the psychopathology being treated. The direct product of

such research is increased understanding of something basic about

human beings, and the evolution of increasingly effective techniques

for helping them to change is best when based on such knowledge.

The indirect product of such research is an ability to draw some

relative, albeit very limited and short-term, conclusions about technique

efficacy.

Because several resources exist on the design and methodology of

therapy outcome research (see especially the excellent and

comprehensive monograph by Lettieri 1992), the present chapter will

summarize in brief form some of these considerations and will

elaborate on those that require special emphasis. To facilitate both

goals, table 1 provides an outline of (1) the basic types of outcome

design and (2) some of the more important features of an outcome

study that need to be considered and the general types of questions to

be asked in making decisions about the potential relevance of each

feature in interpreting a study’s results and about choosing

methodological devices that maximize their unambiguous

interpretation. These questions are the same, irrespective of whether

the investigator’s purpose has to do with drawing conclusions from

existing research or with designing an outcome investigation.

INDEPENDENT VARIABLE CONSIDERATIONS: DESIGNS

Although an investigator may choose any one of the major

between-group design options listed at the top of table 1 to begin a

program of research, the history of evaluative investigation for a

particular therapy typically begins with a no-treatment comparison and

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TABLE 1. Considerations in therapy outcome research.

Independent Variable Considerations:

Designs

No-treatment comparison design

Nonspecific comparison design

Component control (dismantling)

design

Additive (constructive) design

Parametric design

Comparative design

Independent Variable Considerations: Methodology

Random assignment within waves Clients randomly assigned to

conditions within temporal

waves?

Session parameters

Therapy manuals

Integrity checks

Number of sessions and length

of sessions specified? Matched

across conditions? Time and

amount of treatment by a

condition or condition

component not confounded in

dismantling or additive

designs?

Used operationally to define

treatments? Detailed?

Available to readers to allow

evaluation and replication?

Adherence checked by

independent raters? What

percentage of sessions? Found

to have minimal breaks in

protocol? Equivalent

adherence across conditions?

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Table 1. (continued) Considerations in therapy outcome research.

Expectancy/credibility checks Ratings obtained from clients

early in therapy? Equivalent

across conditions?

Attrition (dropout, missing data,

and deterioration)

Client Considerations

Source(s)

Selection criteria

Representativeness

Client characteristics

Total number? Equivalent

across conditions?

Comparisons to completers

provided?

Numbers specified from each

source? Balanced across

conditions? Analyzed for

effect?

Operationally defined?

Reliable? Levels balanced

across conditions?

Numbers of clients screened

for what reasons?

Described? Means, standard

deviations, and/or

frequencies provided?

Balanced over conditions?

Severity and duration of the problem Specified? Means and standard

deviations provided? Balanced

over conditions?

Concurrent and past treatment

and psychosocial treatment

Types and number of clients

specified? Balanced over

treatment conditions? Method

of holding medication

constant? Analyzed for effect?

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Table 1. (continued) Considerations in therapy outcome research.

Diagnosis Structured interview? Diagnosis base

such as Diagnostic and Statistical

Manual (DSM)? Independent

reliability checks on diagnosis?

Therapist Considerations Multiple therapists? Characteristics

described? Training and supervision in

general and in protocol described? Not

confounded with condition? Possibility

of therapist-bias effects?

Dependent Variable Considerations

Multiple domain assessment Valid and reliable measures from

multiple perspectives and methods?

Assessors Characteristics? Blind to condition?

Reliability checks? Multiple assessors

balanced across conditions?

Followup assessment Duration? Completeness? Includes

determination of further treatment?

Clinically significant change Defined in a meaningful way?

Statistical Analysis

Considerations

Pretherapy equivalence across

conditions through nonconservative

tests? Base-free measures of change?

MANOVA on related measures?

Significance of change within

condition? Outcome analyses with and

without endpoint scores? With and

without clients receiving further

treatment by followup? Sufficient

power?

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Table 1. (continued) Considerations in therapy outcome research.

Increasing Basic Knowledge Basic research questions asked through:

in the Context of Therapy Design conditions? Additional

Outcome Design outcome and process measures focused

on client characteristics and sites of

effect? Comparisons to nonclient

samples? Analysis of possible

predictors of outcome?

subsequent attempts to rule out nonspecific factors before proceeding

with more elaborate designs. This is done in recognition of the risks

involved in prematurely choosing a certain type of more powerful, but

more costly, research design as the start point.

No-Treatment Comparison Design

For a technique not yet researched, ensuring that it has effects greater

than those associated with history, maturation, repeated testing,

instrumentation, statistical regression, selection, attrition, and

interactions of these variables with client characteristics through the

use of a no-treatment comparison condition (Campbell and Stanley

1963) is a wise beginning. The design is less expensive in time and

cost, usually yields sufficiently large effect sizes that thus require a

smaller number of clients for adequate power, and provides an

opportunity to rule out the above rival explanations of any observed

differential outcomes sufficient to conclude that something about the

provision of therapy with any or all of its associated characteristics is

superior to nothing at all.

The ordinary no-treatment condition is a waiting-list condition. Ethics

requires that clients in this condition be provided with therapy at the

end of the waiting period. Two further ethical considerations are

associated with this control condition. First, it is essential for the

investigator to have some method of monitoring client status during

the waiting period so that if deterioration in clinical status occurs,

removal from the protocol and provision of appropriate treatment can

take place. This often takes the form of periodic phone contacts with

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the clients and assessment of their psychological state by a clinical

assessor or instructions to the client to contact the project staff if any

worsening of the condition occurs. While such procedures make it

possible that client data will be lost (see the later discussion on the

methods for dealing with missing data and the potential compromise of

the researcher’s confidence in the success of random assignment when

people who deteriorate are removed), ethical treatment of participating

clients takes precedence.

Second, the decision on whether to use a no-treatment condition in the

first place must be carefully made on the basis of knowledge of the

nature, course, and severity of the disorder being investigated in

combination with the duration of the waiting period. The extremes of

this decisionmaking dimension are easy to specify: lengthy waiting

periods before treatment for a severe problem known often to

deteriorate are not defensible from an ethical perspective, whereas brief

waiting periods for analog problems with a benign course are

defensible. Making decisions in the gray area between these extremes

requires careful thought. All of these considerations obviously indicate

that, under the usual circumstances of therapy outcome research, there

is no way to secure long-term followup information on clients who are

left without treatment after postassessment. Outside of the therapy

outcome literature, there are sometimes longitudinal studies and

clinical experience that provide information on the developmental

course of some disorders. These sources of information may give

some indication of the degree of change or lack of change that

ordinarily can be expected from a particular type of clinical sample

over various waiting periods. Moreover, documenting the duration of

and the intensity of fluctuations in the disorder for each client who is

entering the therapy study at the time of the initial interview (although

fallibly based on retrospective report) can provide (1) some empirical

sense of how likely it is that deterioration will occur during the trial

and (2) how long the problem has been present as a baseline against

which to evaluate change during the trial with some (albeit limited)

confidence that any observed change over the typically 3-4 month

therapy period was not due merely to the passage of time and its

associated historical events.

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Nonspecific Comparison Design

From a strong inference point of view (Platt 1964), after conducting a

crucial experiment that rules out some rival hypotheses that might

otherwise explain observed change (e.g., a no-treatment design),

researchers take whatever remains unrejected as a possible explanation

of the cause-and-effect relationship and create a new design with

contrasting conditions that allow the ruling out of further, more

specific rival explanations. What was left over from the no-treatment

study was something about the provision of therapy. Taking this

unrejected portion, researchers can further specify its content and

create comparison conditions that represent differing aspects of that

content. Traditionally in therapy research, this next step often has

involved a division of a therapy into two general parts: those aspects

that are common across most therapy techniques and those that are

specific to the therapy under consideration. All therapies share

common ingredients such as contact with a therapist, attention to the

problem, suggestions that therapy generally will be useful in helping to

change the problem, specific suggestions of the ways in which this

therapy will promote change, and, in terms of the client’s hypothetical

internal process, the generation of faith, hope, and expectancy for

improvement. Researchers are interested ultimately in whether or not a

specific therapy contains active ingredients for change in addition to

these common ingredients. The use of placebo conditions, based

historically on pharmacological research contrasting chemically active

medication with inert substances, became for a while the sine qua non

of psychotherapy research as the vehicle for ruling out the nonspecific

rival hypothesis (Paul 1969). Because of the conceptual,

methodological, and ethical problems that became increasingly

apparent in the use of placebo conditions in psychosocial treatment

research (O’Leary and Borkovec 1978), their deployment in outcome

research with actual clinical disorders has all but disappeared while the

field continues to attempt to develop and use alternative methods to

control for crucial nonspecific effects. Placebo conditions remain

useful, however, in analog samples with mild “problems,” as long as

certain other methodological considerations are taken into account (see

Expectancy/Credibility Checks on page 265).

A commonly used alternative to the placebo condition that circumvents

some of these problems is a “commonly used” or “best available”

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therapy control condition. In this approach, the investigator chooses a

therapy that has no existing empirical data validating its efficacy for

the disorder under investigation but is considered by the practicing

community to be a frequently used or, if some consensus informally

exists, the best clinical intervention that exists. Methodological (see

Expectancy/Credibility Checks on page 265) and ethical (such as

monitoring for deterioration) considerations will remain with this

choice, but they are often not as problematic as they are in the case of

pure placebo conditions.

Component Control or Dismantling Design

In order to control for nonspecific factors in a way that decreases

ethical concerns, conceptual difficulties, and methodological problems

and at the same time potentially generates the greatest amount of

important basic knowledge, the use of the next design, the component

control or dismantling design, is nearly ideal. The investigator

specifies the various methods of a therapy technique and creates

treatment conditions that provide some elements but not others, often

with a final condition representing the entire package of methods.

Ethical considerations are less severe at this point in time because,

even though the package may have been previously determined to be

superior to some other control condition, it is unknown which

procedural element or combination of elements actually is causing the

change-any one of them could be responsible. Methodologically, the

various conditions derived for component analysis are or can be very

closely matched in many procedural details; thus, more factors are held

constant than is the case with alternate comparison conditions.

Empirically, it has been shown that the likelihood of conditions being

equivalent in degree of nonspecific factors is greater to the degree that

the contrast conditions are procedurally similar, but such an equation

needs to be checked through expectancy/credibility scales (see

page 266). Demonstrations of differential outcome among components

or between certain components and the total package provide

extremely useful information regarding both the nature of the

pathology itself and the nature of the therapeutic processes and

mechanisms that lead to change.

Differential outcome among components draws the investigator’s

attention to more precise questions about (1) the factors responsible for

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therapeutic change (e.g., what the mechanisms of change must be like,

so that these particular components impact on the disorder) and (2) the

factors responsible for maintenance of the disorder (e.g., what the

mechanisms of maintenance must be so that these components impact

on them). The empirical outcome limits the possibilities of what those

hypothetical factors might be and guides the investigator’s thinking in

the direction of the most likely possibilities. This especially will be

the case when component designs are used in conjunction with other

methods described later in this chapter that focus on acquiring basic

knowledge about the disorder and change process within the general

context of a therapy outcome research design.

Ethics again requires monitoring for client deterioration, removal of the

client from the study if such occurs, and the provision of alternate

treatment for all conditions. The same is true for the following three

designs as well.

Additive or Constructive Design

A design in which two or more therapy techniques are combined into

one package and are compared to each of the single methods is

identical to the component control design in nearly all respects; such

an additive design has the same methodological and ethical advantages

previously described. Its goal is to create a new therapy by adding

two techniques together, each of which is considered by theory or

empirical results to influence some aspect of the problem such that

their combination would hypothetically provide even greater efficacy.

The distinction between component control and additive designs really

has more to do with historical perspective than with anything essential

to their nature.

An example will clarify this point. Assume the year is 1950.

Someone might already have evidence that relaxation methods are

effective for some types of anxiety. The investigator also might know

from extensive animal learning data that graduated, repeated exposure

to feared situations reduces anxiety. So, this investigator proposes an

additive design to evaluate the separate and combined effects of each

of these therapies in the treatment of a simple phobia. Although

Wolpe (1958) had somewhat different and more elaborate theoretical

and empirical foundations for creating this very package, the actual

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result of this type of thinking and its early research was the

development of systematic desensitization. By 1968, experimental

evaluation of this therapy had entered the component control design

phase (e.g., Davison 1968). Contrasting component conditions were

being used in an attempt to isolate the role of relaxation by itself, the

role of imaginal exposure by itself, and their combination, thus

representing a component control. The eventual results of the use of

these designs led to some rather fundamental knowledge about the

nature of the change process and the nature of fear.

Both component control and additive designs provide rather powerful

tools from the strong inference point of view. Independent variables

are held constant to a greater degree than is the case with other

designs, and there may be no limits on the extent to which

investigators can continue to further break apart efficacious therapy

elements or to combine separate technique elements to test crucial rival

hypotheses regarding therapeutic change on the basis of their

comparison. The labels associated with these two designs, however,

reveal an unnecessarily narrow perspective on their usefulness. It is the

case that two elements may each separately contribute to overall

efficacy in an additive manner. However, the even more exciting

possibility is that one element may catalyze the effectiveness of the

other in addition to whatever additive effects each may have. Indeed,

such a synergistic process was at the heart of Wolpe’s original theory

about change mechanisms in desensitization.

Parametric Design

The creation of comparison conditions based on sampling along a

fundamental dimension of a therapy approach or of a particular therapy

element represents the most theoretically sophisticated design and

provides the greatest methodological opportunity for holding all factors

constant but one. In this design, the investigator chooses what he or

she thinks is one of the most crucial theoretical or procedural

dimensions of the change process induced by a therapy or one of its

elements and constructs conditions that represent differing degrees of

representation along that dimension. Examples of therapy dimensions

from which one could construct contrasting conditions include:

duration of exposure to phobic stimuli; depth of emotional processing;

depth of interpretation; degree of warmth, congruence, and

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unconditional positive regard; variations in schedules of reinforcement

or punishment; degree of therapeutic focus on intrapersonal or

interpersonal process; depth of focus on underlying beliefs; or the

degree to which the developmental origins of an underlying belief are

targeted. Because only a single dimension is being manipulated and

because all clients will be receiving some level of that singular

dimension, the investigator’s ability to match conditions on all other

procedural features is maximal. Because the design can sample more

than two points along the critical dimension, functions can be

determined that provide a much stronger basis for determining actual

laws of behavior (i.e., two points can yield only a linear function that

may not reveal completely the true underlying function). Similar to

the component and additive designs and for analogous reasons, ethical

problems are also less severe.

Comparative Design

Comparing two different therapies representing different theoretical and

historical traditions certainly has a very high profile in the outcome

research literature. There is good reason for the seeming importance

of such investigations. The mental health profession and society in

general, for many reasons, want to know the answer to the question of

which therapies are most effective for which disorders.

The author claims, however, that comparative research of this type

does not provide valid answers. Most comparative studies are of such

limited value for both applied and theoretical purposes that they should

not be conducted. The applied implications of their results are, at best,

of excessively short-term significance even if the comparative

methodology employed were internally valid (which it is not). Further,

the usual ways in which such investigations are conducted preclude the

acquisition of any meaningful basic knowledge. Different therapies

vary from each other in so many ways that the experimental ideal of

holding constant what the client experiences is not even nearly

accomplished; differential outcome could be due to many, many

differences in procedure. Thus, the investigator’s ability to rule out

rival hypotheses is extremely limited, and, consequently, little basic

knowledge will be provided by this design. The design does allow

ruling out nonspecific factors (assuming equation of the therapies on

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this factor; see Expectancy/Credibility Checks, page 265), but only if

differential outcome actually is observed.

The greatest threat to internal validity, however, resides in an issue

surrounding the quality with which each therapy is provided. If

differences between conditions exist in how well the therapies are

conducted, comparison of the conditions is meaningless. In an extreme

hypothetical example, it is obviously not fair to compare one treatment

that is conducted very poorly to another that is provided with high

quality and expertise. So, it is essential for internal validity that the

therapies be matched on the degree of the quality of their provision.

For the sake of ruling out the rival hypothesis of differential quality, it

actually does not matter whether the therapies are matched at

50-percent, 75-percent, or 100-percent quality levels as long as they

are matched. How can such matching be ensured? The therapy

research field has made little progress in addressing this question, and

despite some beginning attempts for some types of therapy (e.g., the

Cognitive Therapy Scale, Vallis et al. 1986), researchers can say that

there currently is no valid way to measure quality for any therapy

technique. Thus, researchers cannot be sure that two different

therapies are equivalent on this crucial, potentially confounding factor

in comparative studies.

To minimize this problem, some investigations have employed expert

therapists from each therapy tradition who conduct only their own

therapy in the comparative trials. However, three problems remain.

(1) This approach does not provide measured information on quality.

(2) It is difficult to know for certain that expert therapists in one

tradition provided quality equivalent to that provided by experts in

another very different therapy. (3) The use of separate experts for

each condition inherently confounds therapy condition effects with

therapist characteristics, a significant problem for internal validity (see

Therapist Considerations, page 276). The quality issue is ordinarily

much less severe in the case of component, additive, and parametric

designs because the therapists are typically trained in and clinically

experienced with each element to an equal degree. If a therapist has

been trained in desensitization and if he or she serves as a therapist in

a component study contrasting relaxation therapy alone to relaxation

plus imagery exposure, it is highly unlikely that this therapist would

provide differential degrees of quality of relaxation training for clients

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in the two conditions. Absence of valid measures of that quality still

precludes empirical certainty of this, however.

Even if researchers could solve these methodological problems, a

demonstrated differential outcome in a comparative trial would have

only limited applied significance. Researchers could conclude that this

one therapy is more effective than another, but for how long would

this be a meaningful conclusion? Each therapy technique is

undergoing constant modification based on further clinical experience,

theoretical developments, and empirical information about its

mechanisms of change and the nature of the pathology that it treats.

Thus, researchers can reasonably expect on the basis of the past

therapy developments that the efficacy of a particular technique and

knowledge about the specific client or therapist characteristics best

predictive of favorable outcome with a particular therapy will improve

over time. Any comparative demonstration is, at best, a comment on

relative efficacy at a particular point in time, with unknown future

relevance as each method experiences growth and change at unknown,

but probably differential, rates over time.

In summary, by their nature comparative outcome studies provide little

basic knowledge by virtue of their inability to hold things constant and

their limited internal validity by virtue of the currently unresolved

issue of the potential confounding factor of differential quality. Thus,

they yield little in either basic knowledge or applied significance, and

their outcome would have only short-term significance even if these

serious problems were to be overcome. The alternative approach is to

go deeply into one therapy technique, using increasingly sophisticated

designs, methods, and measures that explicitly provide basic

knowledge about the pathology and the therapeutic change mechanisms

of that therapy from which to devise hypotheses about increasingly

effective modifications of that therapy.

Besides the basic design choices for therapy outcome research,

researchers must take into account a variety of additional

methodological considerations. Table 1 summarizes the major domains

and the types of issues relevant to each domain.

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INDEPENDENT VARIABLE CONSIDERATIONS:

METHODOLOGY

Random Assignment Within Waves

Rarely in large-scale outcome research am all clients available at the

same time. More often, referrals come continuously over the duration

of the project period, which can last in some studies for 3 or 4 years.

Because of possible seasonal variation, changes in the experience level

and expertise of the therapists in conducting protocol therapy, changes

in the experience of assessors, changes in personnel, and other

considerations, ensuring that clients in each condition are balanced for

such factors requires that random assignments be conducted within

each consecutive wave of clients who become available for the

treatment trial.

Session Parameters

To avoid confounding conditions with the amount of treatment

provided, conditions need to be matched on the number of sessions

and the length of each session. A particular problem arises when using

those component control or additive designs in which treatment

elements are contrasted with a combined package. In this instance, a

confounding factor of either the total amount of treatment time or the

amount of therapy devoted to any particular element exists. For

example, if one were to compare therapy A to therapy B and to the

combination of A and B, the combined group necessarily will receive

either twice the amount of therapy time that A and B receive, yet still

be given the full amount of exposure to each therapy, or it will receive

only half of the amount of exposure to each therapy, yet be matched

for total treatment time. The former methodological choice results in a

rival hypothesis that total treatment time accounts for between-group

differences, whereas the latter results in confounding the amount of

exposure to each element. One solution to this problem would be

provided if the study was conducted twice, once with one confounding

factor present and once with the other confounding factor present. If

similar between-group differences emerge, both rival hypotheses could

be ruled out. Because this is an expensive solution, the more frequent

method is to match conditions on total treatment time within an

individual study by adding “best available” or other nonspecific

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elements in the therapy sessions of the single-element conditions to

increase the total amount of therapy time to match that of the

combined condition. In this way, all conditions receive equal amounts

of any active treatment components without an imbalance in the total

time in contact with the therapist.

Therapy Manuals

Perhaps the single most important development in therapy research has

been the creation of clear, detailed, well-operationalized definitions of

the independent variable through the use of therapy manuals. The

protocol manual provides several advantages: it allows for replication

of therapy studies by other investigators, provides a basis for

evaluation of the faithfulness and adequacy of the specific methods to

the original theory and therapy technique from which it was derived,

and maximizes the likelihood that the therapists in a study will adhere

only to those procedures allowed by each particular therapy being

investigated. A well-constructed manual specifies the conceptual

underpinnings of the technique, the rationale given to the client for

understanding his or her problem based on this conceptualization, and

the particular procedures that arc to be used to facilitate therapeutic

change.

The greater the degree of detail provided, the more the manual

accomplishes its purposes. The best manuals give (1) session-bysession outlines and elaborations on the content within each outline

step sufficient for the therapist to be able to follow the proscribed

procedures as stated with every client and (2) specific guidance

through clear statements of the theory underlying the technique so the

therapist can deduce what specific interventions should be used in any

given circumstance. The former provides the basic methods to be used

with every client, whereas the latter allows for the needed flexibility to

respond to the unique nature of each client while still remaining within

the spirit of the therapy’s protocol. Of course, the same degree of

detailed instruction needs to be provided within protocol manuals for

each therapy condition being investigated in the study.

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lntegrity Checks

Although the use of well-defined manuals is extremely important for

the above reasons, there is no guarantee that the therapists actually do

adhere to the protocol with every client or in every portion of every

session. An essential check on protocol integrity involves independent

ratings by staff knowledgeable in all of the various protocol

techniques. These checks are conducted by randomly selecting an

equal number of sessions for each therapist in each condition (typically

20-25 percent of all sessions) and by categorizing every therapist

utterance from the audiotape of the entire session onto a checklist of

protocol-allowed and not-allowed interventions. The latter checklist

ideally includes all of the procedures involved in any of the contrasted

therapy conditions as well as methods of therapy from other therapy

traditions that are not explicitly a legitimate part of the investigated

condition. Some operational definition of major and minor breaks in

protocol needs to be established along with decisionmaking rules for

when a client’s data will be excluded due to significant departure from

proscribed procedure. This approach is the most thorough, and it best

precludes any confounding between conditions either from the

contamination of one condition’s unique methods with the methods of

another condition or from the inappropriate use of techniques outside

of the theory or therapy methods being evaluated. Less complete

approaches to adherence rating have been employed (e.g., mere

judgment about which condition was being conducted after listening to

the entire session or sampling only a small portion–5-10 minutes–of

a session), but these are largely inadequate to provide the empirical

assurance of integrity that is required. It is essential that nonprotocol

statements are found to be minimal in frequency and that study

conditions do not differ in the frequency of such statements; otherwise,

a confounding factor exists.

Expectancy/Credibility Checks

A central goal in attempts to control for nonspecific factors is to

ensure that all therapy conditions in the trial are equivalent in their

generation of expectancy for improvement and in the degree to which

demand characteristics may contribute to client reports and behaviors

at postassessments. Just because the treatment conditions are

procedurally matched on the amount of therapist contact and attention

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to the problem, the presentation of a meaningful rationale for the

treatment, the provision of suggestions, and other factors, this does not

necessarily mean that the conditions are equated on how much

expectation and demand actually are generated in the client. The

frequently used method to assess the degree of equivalence among

conditions on these crucial elements of nonspecific influence has been

the administration of expectancy/credibility scales early in the therapy

trial. The expectancy scale asks the client to estimate the percentage

of improvement that he or she expects to occur by the end of therapy,

whereas credibility scales ask for ratings of how logical or believable

the rationale and methods of treatment being offered appear to be and

how willing the client would be to recommend such treatment to a

friend who has the same type of problem. Ordinarily, such scales are

given once the client has heard the rationale for the type of treatment

that he or she will be receiving and a description of, if not actual

exposure to, all of the intervention methods to be employed based on

that rationale. It is important to obtain these ratings at an early point

in therapy (often at the end of the first session) because client attitude

about such factors may change over the course of therapy in response

to actual improvement or lack of improvement and thereby confound

the assessment.

Attrition

At each stage of the selection process, there likely will be clients who

decide not to participate. As long as random assignment does not

occur until a client is about to begin the first session, early termination

is not a problem for internal validity, although it does affect

generalizability. More importantly, virtually all clinical outcome

studies will have attrition due to clients choosing to discontinue their

participation after the start of their therapy (“dropouts”). Reasons for

noncompletion may be varied, but they commonly include

dissatisfaction with the type of therapy or the therapist, failure to

experience any signs of improvement soon enough, excessive

discomfort with the emotional experiences generated by the treatment

(e.g., relaxation-induced anxiety in response to relaxation training),

perceived lack of time to commit to sessions or to required homework

assignments, and leaving the geographic area. Much has been made of

the presumed devastating effects of dropout on the internal validity of

a therapy investigation (e.g., Howard et al. 1990). The valid point is

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this: if internal validity depends partly on the success of random

assignment to distribute known and unknown client characteristics

equally across conditions such that researchers can assume with

statistically specifiable likelihood that the conditions am held constant

on these variables and thus do not confound interpretations of

condition differences, then any loss of clients after random assignment

destroys confidence in this equation. Although researchers should

compare dropout clients with completing clients by using all measured

pretherapy demographic and outcome assessment variables, and,

furthermore, again compare conditions using only the completing

clients (with a demonstration of equivalence in both cases increasing

the likelihood that these known variables do not confound the

interpretation of results), there is no way that they can be sure that the

conditions did not differ on unknown, unmeasured variables. Thus,

there is no way to be confident that between-group differences in

outcome are caused by the crucial condition manipulation.

The important point to be emphasized, however, is that everything

researchers do in experimental research rests not on certitudes but on

probabilities. In the present case, this means that the likelihood of

undermined equivalence due to dropout falls on a continuous

dimension of probability, and the best guess about where along that

dimension a particular study falls depends on the size of the dropout

rate. Again, extreme examples help to clarify this point. If only one

client terminates prematurely out of 75 clients, there will be little, if

any, impact on the assumption of initial equivalence of conditions. If

40 clients fail to complete the trial, the likelihood of equivalence

among conditions with remaining clients is much reduced. Even in the

latter example, however, the conditions have some probability of still

being equivalent on all known and unknown client characteristics,

although that probability is less than in the previous case. Because

researchers have no way of knowing about the unknown, they cannot

know where to draw the line between too much dropout and not

enough dropout. Nor would they want to, because all rests on

probability dimensions, not all-or-none decisionmaking. So, with no or

small dropout, researchers are more confident in the absence of client

characteristic confounding factors; with large dropout rates, they are

less confident and need to point this fact out in their paper as a

potential limitation on their conclusions.

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Another crucial issue involves differential dropout among conditions.

In itself, this is important empirical information regarding the range of

applicability and consumer acceptability of the therapy techniques, but

it also has implications for internal validity. The greater the

differential dropout rate, the less probable it is that completing clients

were equivalent between conditions before therapy began. There is

less concern over (i.e., less probability of) confounding effects when

dropout rates are equivalent. Dropout in general and differential

dropout among conditions both have two possible elements: those

independent of the type of therapy condition and those attributable to

the type of condition. Notice that many of the reasons for early

termination mentioned earlier could be either common for all

conditions or specific to a particular condition. In the case of common

reasons, initial random assignment allows a reasonable (probabilitybased) assumption of equivalence between conditions in likely

frequency of termination, reasons for termination, characteristics of

terminators, and initial characteristics among completing clients

(i.e., no confounding with condition). Differential dropout for either

type of reason is more problematic, but again only in terms of reduced

probability of initial equivalence and, thus, in the increased probability

that one or more client characteristics confound the therapy conditions.

Like total dropout rate, differential dropout due to common reasons

reduces confidence in condition equivalence in increasing degrees as

the amount of dropout discrepancy between conditions becomes

greater. In the case of differential dropout specific to the type of

therapy, researchers have in addition even less confidence that

terminators do not differ from nonterminators differentially between

conditions on other characteristics because in this instance there is not

a common stimulus to which they are responding.

In summary, dropout and differential dropout are problematic for

interpreting results because they lessen the likelihood that the clients

compared at postassessment were comparable at the start of therapy on

all known and unknown variables, but it is essential to remember that

these problems are always a matter of degree. As the size of attrition

or the degree of discrepancy in differential attrition due to dropout

increases, the probability of nonequivalence grows. However, this

does not necessarily mean that the conditions are confounded by client

characteristics at all. Additionally, in a certain sense, this entire issue

is an empirical question. The reference is not to what a single study

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might tell researchers or to being able to know the unknown (which is

really the fundamental problem associated with the possible effects of

attrition), but it is linked to the patterns of results from several

replication studies over time, each involving varying degrees of

attrition. A very meaningful, bottom-line question is this: historically,

what is the evidence that this fallible procedure-for which logic

dictates the possibility that random assignment does not do its crucial

job because of the attrition enigma-has still produced significant and

unconfounded conclusions about the relative effectiveness of a therapy

or its components and has led to increasingly effective developments

and modifications of that therapy based on those results? To this

observer, there are several clear and compelling examples in which the

answer is unequivocally affirmative; the cognitive model of panic and

its associated treatment methods is a very good case in point.

Identifying common reasons for early termination and the development

of methods within a therapy technique and in general to reduce its

likelihood is an important area of clinical concern and research in its

own right. Attrition during the screening process and after therapy has

begun potentially affects external validity, and it may relate

importantly to the issues of consumer acceptability and usefulness.

Interestingly, however, the dropout problem is, in some significant

ways, no different than the one faced by practicing clinicians. The

modal number of sessions in general clinical practice is very small and

indicates that many clients are therapy “dropouts.” With this

realization comes the ironic conclusion that an outcome study without

dropout lacks a certain kind of external validity to the real clinical

world.

One further consideration should be mentioned. The ideal procedure

under the unfortunate circumstance of dropout is to conduct

postassessments with terminating clients, both to identify the reasons

for terminating and to obtain outcome measures. Although some

clients may be unwilling to do so, many will. How to incorporate this

information into data analyses will be discussed later.

Finally, two additional subcategories of client attrition are important to

mention: (1) people who deteriorate and are removed for ethical

reasons from the protocol because of clinically significant worsening of

the problem and are provided with clinically sensitive, nonprotocol

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therapy and (2) missing-data clients who are unwilling, unable, or

unavailable to complete followup assessments. In terms of how these

bear on the interpretation of results, the same comments outlined above

for dropout clients can be made about both subcategories in all

respects. Thus, it is similarly important to report the number of clients

in each condition falling into each subcategory and to take these results

into account when drawing conclusions. In the case of missing data,

there are some additional considerations regarding statistical analysis,

but these will be considered later.

CLIENT CONSIDERATIONS

Sources

Clients participating in therapy research potentially can come from

various sources. The most common examples include: referral from

other agencies or private practitioners, referral within the inpatient or

outpatient services of the hospital in which the project is housed,

self-referral to the project, and response to advertisements in the media

announcing the availability of treatment. Indicating the number of

contacts from each source is important for providing a basis for

characterization of the client sample and for judging the

generalizability and clinical relevance of the findings. Furthermore,

ensuring that client sources are distributed evenly over the different

treatment conditions of the project is essential in order to hold this

variable constant. Initial analyses contrasting clients from different

sources on demographic characteristics, pretherapy levels of dependent

measurement, and outcome change can identify whether or not source

variation makes a difference with this particular disorder.

Selection Criteria

Operational definitions of selection criteria for client participants need

to be specified for required characteristics and those characteristics that

would preclude a client from being entered into the therapy trial.

Some common examples are gender, intelligence quotient, age, severity

and duration of the problem, types of problems or primary and

additional diagnoses, and status on certain co-occurring medical or

psychological problems. Different studies may treat such features

differently (e.g., some studies of an anxiety disorder may exclude

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clients with moderate or severe depression, whereas others may include

depression as an additional factor). The important requirements are

that all such criteria are specified, that they are reliably determined,

and that they are based on a valid rationale related to the nature of the

disorder and the nature of the questions being asked in the therapy

investigation. Furthermore, when such features are variable within the

selected sample instead of being held constant at a chosen level, it is

essential that those features are balanced over conditions to reduce the

chance of differential representation and consequential confounding of

the experimental manipulation. Carefully chosen criteria maximize the

homogeneity of the sample on those characteristics thought to be

critical to an understanding and treatment of a disorder (thus reducing

error variance) and allow a determination of the extent of the

generalizability of the study’s findings. In general, the more restrictive

the selection criteria are, the less the likelihood that subject-related

confounding factors exist between conditions, but the lower the

generalizability of the findings to samples with differing characteristics.

Representativeness

Tracking the number of client contacts with the project and recording

reasons for exclusions allows a determination of the characteristics of

the entire group from which the study sample was selected. Such

information bears on generalization issues for a particular study, but it

also provides heuristic data on the number of clients who have the

target problem. Other therapy trials might be developed in the future

for those clients. The ultimate result might be new therapeutic

developments and research areas and eventual empirical extension or

restriction of generality. A good example might be a controlled trial

for helping depressed women in dysfunctional marriages and

contrasting cognitive therapy with and without marital therapy. Both

depression level and quality of the marital relationship would be

among the critical selection criteria. A colleague recently discovered

that, whereas large numbers of appropriate clients wished to

participate, the partners of many refused to enter couples therapy

(Mark Whisman, personal communication, August 1992). The results

from such a study would be limited to clients whose spouses agreed to

participate, but this investigators experience also suggested the

importance of developing and evaluating therapy methods specifically

designed for the other women and focused on the difficult and largely

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unresearched area of helping individuals to cope with, and perhaps to

change, a dysfunctional relationship without the cooperation of the

partner.

Client Characteristics

Whether or not various client characteristics are used as selection

criteria, it is important to describe clients in the trial sample to allow

evaluation of generalizability and to analyze for condition equivalence

to ensure absence of possible confounding features. Critical

characteristics may vary depending on the nature of the problem being

treated; common examples include age, gender, ethnicity, medication

status, marital status, and education level. Providing means and

standard deviations (or frequencies for categorical data) by condition

will facilitate evaluation of the study itself as well as the possible use

of its data in future reviews or meta-analyses. Testing for condition

equivalence should be nonconservative (e.g., using t-tests or one-way

ANOVAS on each variable rather than using either MANOVA on all

variables or Bonferroni corrections of alpha when conducting multiple

tests). Actual test results need to be reported; two groups that do not

differ significantly in mean age with p < 0.10 have a greater chance of

an actual confounding age factor than if p < 0.05. Whereas with

p < 0.50, researchers would have less concern that age differences

account for outcome differences between the conditions.

Severlty and Duration of the Problem

From the point of view of selection criteria, sample description, and

the need for condition equivalence, the characteristics of severity and

duration of the problem are no different than the others described

above except that they warrant special mention because of the degree

to which they are important in characterizing the sample and

potentially confounding of interpretation if they differ at all among

conditions. Pretherapy scores on the various measures of both the

central problem and any associated problems are inherent aspects of

outcome measurement. So, information on operational definitions of

severity are available routinely in study reports. They must, however,

be valid and reliable assessment devices, not only for reflecting

therapeutic change but also for characterizing the degree of clinically

meaningful problems in the selected sample. Thus, the use of some

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measures for which there is preexisting empirical information on how

well they distinguish the disorder being treated in the research trial and

the means and cutoff scores for disordered and nondisordered groups

would facilitate evaluation of this issue. In many outcome study

reports, information on the duration of the problem is lacking or

incomplete. Some device (interview or otherwise) should be used to

specify as accurately as possible how long the problem has been

present. Some studies report a minimum duration as a selection

criterion, but this does not replace the requirement that average

duration and its variance for each condition be specified. As was the

case earlier, nonconservative preliminary analyses of condition

similarity or difference on the pretherapy levels of the principal

outcome measures and duration of problem are essential, and full

report of means and standard deviations by condition should be made.

Concurrent and Past Treatment

Outcome studies have varied in how they handle the presence of

concurrent pharmacological or psychosocial treatment and any history

of exposure to therapy. Often, no information is provided, so one

cannot evaluate the possible influence of such factors. Two

approaches have been used with regard to the presence of concurrent

medication when it is reported. One approach excludes clients on

psychotropic drugs. In this case, treatment condition differences are

not confounded by medication status, but external validity is lessened.

This generality issue may be important, particularly with disorders in

which drug treatment is very common. Furthermore, it is important to

determine with each client whether he or she independently has

obtained psychotropic medication during the course of the therapy trial

to ensure that a potential confounding factor has not emerged since the

beginning of trial participation.

The second approach is to include clients on medication, thus

increasing external validity. There are likely to be further stipulations

associated with this. Some investigators admit clients on medication

only if they have been using the medication for several months. This

suggests that drug effects have stabilized, but a significant problem

level (indicated by severity selection criteria, for example) still

remains. Moreover, not all drugs necessarily will be allowed. In the

generalized anxiety disorder program at Penn State University, for

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example, use of antidepressive medication is an exclusionary criterion

because the drug effectively may be controlling or masking a severe

depression, and severe depression is an exclusionary criterion for this

program in its own right.

If medication in any way is allowed, it is important to add certain

methodological features that lessen threats to internal validity and

maximize the amount of useful information about the effects of

medication in the context of the particular investigation. First, clients

should agree, with knowledge and consent of their prescribing

physician, to maintain customary pretherapy dosage and frequency

until postassessment is completed. Otherwise, increases or decreases

in medication during the trial could result in outcome changes

(improvement or worsening) that are not a function of the treatment

condition to which the client had been assigned. Second, it is essential

that medicated clients be distributed equally over conditions to

eliminate the confounding factor inherent in differential drug status

among the conditions. Third, analyses of pretherapy information and

pre-post-followup change should examine the main effect of the

medication factor and its interaction with the psychosocial treatment

conditions.

Concurrent psychological treatment can be viewed similarly, although

it is often an explicit exclusion criterion because of the long-standing

view of many in the profession that participating in two different

therapies at the same time can adversely affect the usefulness of both

of them and create antitherapeutic conflicts within each. A few

exceptions have allowed outside treatments as long as the problem

being treated is unrelated to the disorder targeted in the controlled

therapy trial. This can be a risky judgment, however, given that

insufficient knowledge of the variety of psychopathologies and

problem areas does not always allow researchers to draw confident

conclusions about this in individual cases. If concurrent treatment is

allowed, however, information on the number of clients receiving what

kinds of treatments for what kinds of problems should be reported, and

balanced representation of the presence of outside treatment across

conditions is required. Again, statistical analyses of the impact of this

factor should be reported.

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Past psychosocial treatment experience is rarely reported, although

some studies have excluded clients who have received therapy in the

past that is similar to the methods available in the treatment trial. The

assumption is that continuation of the problem, despite adequate prior

provision of a particular technique, indicates the likely ineffectiveness

of that technique for this particular client and that inclusion in the trial

would consequently bias the results for that method when compared to

other conditions. Past medication treatment is reported more

frequently, although its relevance to the current trial is minimal if the

clients have not been taking the medication for a suitably long period

(depending on the type of drug, its dosage, and the duration of its use)

before the start of the psychosocial treatment.

Diagnosis

In many therapy outcome investigations, a specific diagnostic group is

the focus, and the selection criteria include the diagnostic criteria for

that disorder. When this is the case, there are further methodological

requirements to be met. First, the particular system of diagnosis needs

to be indicated. The most frequent is DSM. Second, the operational

definition of the interviewing approach for making the diagnosis

should be explicit and based on an accepted method. This often means

the use of a previously developed semistructured interview. Finally, it

is often essential to include reliability checks on diagnosis along with a

report of the results from reliability analysis (e.g., interclass correlation

coefficients). The ideal method involves the use of two independent

interviews conducted in their entirety by two different well-trained

clinical assessors. Some diagnostic categories have an ordinarily high

degree of inter-rater reliability; in this case, only periodic checks with

dual interviews would be necessary. For other disorders, diagnostic

agreement has been shown to be very poor. Generalized anxiety

disorder is a good example; kappas typically are below 0.60 (Barlow

1988). In this case, it is very important to have dual interviews on

every case, and admission to the trial contingent should be based on

both assessors agreeing that the diagnostic criteria for inclusion are met

or based on staff consensus in the case of disagreements. Although

some false negatives will be excluded, there is significantly less

likelihood that false positives will be entered. This increases the

homogeneity of the sample on the most crucial and relevant subject

characteristic and reduces a significant source of error variance.

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An alternative to the independent interviews involves two assessors

listening to the same live or taped interview and making independent

diagnoses. Although this is better than no reliability check at all,

clients often can change their responses to critical diagnostic questions

between interviews; they have had time to think about the questions

further between interviews and may realize that a different answer is

more accurate or mom likely to gain them entrance to the project.

THERAPIST CONSIDERATIONS

Similar to the specification of client characteristics, the therapists

conducting the treatments should be described in terms of background,

training, and experience, both in general and with regard to the specific

protocols employed in the study. Most typical in clinical research has

been the deployment of Ph.D. clinical staff, advanced clinical graduate

students, or a combination of the two. Weekly supervision by the

principal investigator is a commonly employed method to increase

adherence and quality of therapy provision. For the sake of both

internal and external validity, it is essential that more than one

therapist conduct the treatments, With only a single therapist, therapist

characteristics alone represent a major rival hypothesis for any

observed differential outcomes. To avoid a therapist-by-condition

confounding effect with multiple therapists, each therapist should be

assigned an equal number of clients in each condition. As mentioned

above when discussing comparative research design, there are

situations in which the investigator deliberately chooses to confound

condition and therapist factors. In this case, it is essential to realize

that differential outcome would be attributable only to the particular

therapy-therapist combinations, not at all to the treatment conditions

per se. Such a limitation may or may not be very important,

depending on the nature of the questions being asked and the particular

moment in the history of research findings on the therapies being

investigated.

There is one particular therapist characteristic that may confound an

investigation and has not yet been addressed fully in outcome

methodology. A therapist’s bias or preference for one condition over

another could potentially lead to subtle, undetectable differences in his

or her general behavior during client contacts. These differences

potentially could impact on nonspecific factors and on the expertness

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with which a particular condition is offered and, thus, on the outcome.

There exists only one certain methodological solution to this problem,

and it has been used rarely because it is exceptionally conservative and

therefore risky. If all of the therapists in a study are well trained and

thoroughly experienced in a particular therapy tradition, if these

therapists are trained in a new method for the specific purposes of a

study, and if the comparison of the familiar technique to the new

technique yields significantly greater change for the latter intervention,

then one could rule out therapist bias. One of the rare examples of

precisely this set of conditions was reported by Paul (1966) in his

comparison of insight-oriented therapy and systematic desensitization

in the treatment of speech anxiety. Such an outcome in the context of

this methodological feature provides a conservative estimate of the

relative efficacy of the nonpreferred therapy because even therapist

bias could not overcome the superiority of that nonpreferred

intervention. As is the case with most rival hypotheses, the potential

for the confounding effect of therapist bias in any particular design is a

matter of degree. There is less likelihood of its contribution in

dismantling, additive, and parametric designs than in nonspecific

designs or in comparative designs in which therapists are crossed with

conditions but have differential experience in the contrast conditions.

The reasons for this reduced likelihood are the same as those

mentioned previously for lessening the concern about the quality of the

therapy conditions in the former designs. Also, the possibility of bias

affecting results probably is lessened in comparative studies in which

expert therapists treat clients only in the condition for which they are

expert; presumably, bias is held constant because therapists in each

condition prefer the therapy that they are providing and they are not

administering the other condition(s).

DEPENDENT VARIABLE CONSIDERATIONS

Thorough discussion of measurement issues occurs elsewhere in this

monograph (Moras, this volume), but there are certain methodological

features that require emphasis.

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Multiple Domain Assessment

Multiple measures from different domains of assessment

(e.g., cognitive, affective, physiological, and behavioral) and from

different methods of assessment (e.g., pre- and post-assessment

questionnaires, daily diaries, assessor ratings from interviews,

observational measures, significant-other reports, and physiological

laboratory assessments) provide more compelling outcome assessment

than single domain measurement by a single instrument for the sake of

providing converging and valid improvement indices. Moreover,

depending on the type of problem being treated, outcome might

usefully be defined and measured both in narrow ways (measures of

the specific problem) and in broad ways (general functioning in

various life areas).

Assessors

Any assessment staff involved in the collection of data must be

unaware of the client’s therapy condition; the same requirement would

be a useful recommendation for data managers. If more than one

assessment staff member is involved in data collection, it is crucial that

they are balanced over treatment conditions. Ideally, especially if

assessment includes staff ratings or interview measures, having the

same staff member conduct all of the assessments (including followup)

for a particular client would reduce error variance within a client’s data

due to assessor characteristics.

Followup Assessment

Evaluating the long-term maintenance of therapy is a crucial aspect of

outcome research. Given the typically tremendous cost of large-scale

therapy investigation in time, money, and emotion as well as the

critical nature of the maintenance question, a thorough followup with

its relatively small cost is more than just recommendable; it should be

required. Little standardization exists in the outcome literature

regarding followup assessment. First, length of the followup period

varies from none at all to as long as 2 or even 3 years. In general, a

minimum of 1 year would be a wise choice. Second, studies differ in

the completeness of the followup assessment. Some repeat all of the

same measures used at the posttherapy assessment and follow the same

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procedures. Others merely select one or a small subset of the most

easily obtained measures, often through materials mailed to clients.

This creates highly nonstandardized assessment circumstances that

likely increase error variance. Complete assessment is the wisest

choice. Third, very few studies assess at followup whether clients

have received further treatment after their participation in the therapy

trial. This is a critical piece of information because conclusions about

maintenance effects for any condition cannot be drawn if confounding,

additional treatment were to be received. The degree to which this is

true is a function of how many clients in that condition received such

additional therapy and how much therapy was provided. Moreover,

conclusions about differential rates of maintenance are compromised if

comparison conditions differ in the frequency or extent of further

treatment. In the case in which medicated clients were originally

admitted to the trial, data on patterns of drug use during followup also

would provide important outcome information in and of themselves

and in relationship to potential between-condition confounding factors.

Clinically Significant Change

Even though statistically significant change may occur by the end of

therapy, there is no assurance that the change is clinically meaningful.

Although there are a variety of methods for translating continuous

scores on psychometrically sound outcome assessment devices into

categories representing high, moderate, and low degrees of clinically

meaningful change, two generic approaches are becoming common.

One involves the operational definition of “responder status” (i.e., the

percentage of clients in each condition who show any improvement on

a given measure). This often is defined in a somewhat arbitrary way

to be a 20-percent change from the pretherapy level or, alternately, a

postassessment score with an effect size (e.g., postassessment score

minus preassessment score divided by the preassessment standard

deviation) that falls one standard deviation below the pretherapy mean.

Sometimes investigators define a “responder” as one who shows such

improvement on a majority of specified, crucial outcome measures; at

other times, the percentage of clients meeting this criterion on a small,

moderate, or large number of all of the outcome measures (e.g., with

eight measures, the percentage of clients with 20-percent or more

improvement on zero to two, three to five, and six to eight measures)

is reported. Responder status is a relatively weak criterion for

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clinically significant change, but it does convey how many clients

showed at least some response to treatment. It is also a common

method for determining nonresponders at postassessment and relapsers

at followup, all of whom then are provided with additional treatment

after the assessment. Although this has implications for the

interpretation of the followup data of such clients, outcome researchers

increasingly are viewing this situation from an ethical perspective and

choosing to place client welfare at increasingly high priority. The

second approach used, often in conjunction with the first, is the more

stringent definition of “endstate functioning rate” (i.e., the percentage

of clients in each condition who achieve “normal functioning” levels

on a given measure). “Normal” is defined by posttherapy scores that

fall within a standard deviation of normative means or, in the absence

of such information, below a face-valid cutoff score representing an

adaptive level. Again, the investigator may define high, moderate, and

low levels of endstate categorization through the achievement of such

“normal” scores on a specified majority of main outcome measures or

through report of the percentage of clients meeting this criterion on a

small to large number of all outcome measures. Although standardized

agreement on the precise definitions to use has not been achieved yet,

progress obviously has been made, and the importance of such

definitions for drawing conclusions both about cause-and-effect

relationships for theoretical purposes and about relative efficacy along

a clinically meaningful dimension is becoming widely accepted.

STATISTICAL ANALYSIS CONSIDERATIONS

A full discussion here of appropriate methods for analyzing outcome

data is precluded by both the scope of this chapter and the limited

knowledge of the author. However, some salient points should be

emphasized.

First, as mentioned throughout the text, nonconservative tests for

condition equivalence on pretherapy demographic and dependent

variables should be reported before presenting the outcome results.

Second, it is advisable to conduct primary outcome analyses on

base-free measures of change. The most common choices are analysis

of covariance and residualized gain score analysis. The reason for this

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is the desire to reduce as much error variance as possible in outcome

tests, and statistically removing the contribution of variations among

clients in their pretherapy scores from their subsequent assessment

scores contributes to that goal. This is advisable, whether or not

condition differences existed in pretherapy scores, and is necessary for

a particular measure when there are pretherapy differences on that

measure. The emergence of a pretherapy difference, despite random

assignment attempting to prevent this low probability event, is an

unfortunate circumstance, nonetheless. Although the use of

covariance-adjusted or residualized gain postscores statistically

removes the influence of pretherapy scores, there is no guarantee that

the clients in the different conditions are psychologically equivalent.

For example, if one group is more severely disordered than another, as

partly reflected in a specific pretherapy measure, this difference has

potential implications for differences in the psychological process and,

therefore, for possible differential responsiveness to treatment.

Consequently, when conditions do differ at pretherapy, conclusions

must be drawn cautiously from the outcome results, even if base-free

measures of change were used. As always, this caution is a matter of

degree (probability) that depends on the number of pretherapy

measures that differed between conditions and the size of those

differences.

Third, because it is advisable to use multiple measures from multiple

domains to provide converging assessments of outcome improvement,

a significant (statistically specifiable) likelihood exists that some

measures will show significant condition effects due to chance, and

this likelihood increases as the number of measures increases.

Consequently, it is essential to take this into account by using

statistical adjustments that reduce their likelihood of occurrence. The

most common methods include (1) Bonferroni adjustments of the alpha

level required before a condition effect on a measures will be

considered significant (e.g., with eight outcome measures requited

p-value < 0.05/8, or .0063) and (2) multivariate analysis of variance on

sets of multiple outcome measures the preferred method. In the latter

case, a single MANOVA can be conducted for all of the outcome

measures together. More likely, because of the partial independence of

some measures (different outcome measures arc measuring somewhat

different problems or aspects of the problem), separate MANOVAs can

be run on distinct sets of variables. Each set is composed of (1) scores

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obtained from the same measurement domain (e.g., all behavioral

measures and all self-report measures), (2) scores reflecting the same

construct (e.g., all anxiety measures together or all depression measures

together) or, most appropriately, (3) factor scores derived from a factor

analysis of the entire group of outcome measures in order to establish

empirically the separate sets of measures for MANOVA analysis. If a

significant condition effect is found, followup univariate ANOVAs

with posthoc comparisons to identify which condition or combination

of conditions specifically differed from other conditions on which

specific measures will complete the analysis.

Fourth, even though conditions are found to differ significantly in the

degree of change from the previous analyses, this does not indicate

whether or not a specific condition actually showed a significant

change in a dependent measure. In fact, it is possible for one

condition to show a small (but nonsignificant) increase in a measure

and another to show a small (but nonsignificant) decrease while the

between-group comparison indicates significant difference in the

degree of change. Commonly, within-condition t-tests are reported to

demonstrate whether a particular condition actually showed a

significant degree of increase or decrease on a particular measure

between any two assessment periods. This test is particularly

important for testing whether or not a condition is showing (from

postassessment to each of the followup assessments) maintenance,

further improvement, or a return to pretherapy values.

Fifth, if some clients have received additional treatment since the time

of postassessment, this potential influence on followup scores needs to

be taken into account. The typical method is to analyze the results

separately-with and without inclusion of the data from these clients.

A similar approach can be employed when missing data exists at

followup, except that here the measures are analyzed with and without

the use of endpoint scores (i.e., the score obtained at the last completed

assessment substituting for the subsequent missing score). Neither of

these methods is without interpretive problems. Further treatment

potentially confounds both (1) the effects of trial therapy depending on

how many clients were involved and (2) condition comparisons to the

extent that differential amounts of additional therapy were received

among the conditions. The same can be said for missing data.

However, if outcome analyses differ little in results irrespective of

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these variations, researchers would have greater confidence (though no

certitude) that these factors do not explain all of the effects.

Finally, it is important to realize that the absence of a difference in

outcome between any two conditions may be due to insufficient power

(i.e., the number of clients in the trial was too small to detect the

difference). Thus, researchers need to be very cautious when

concluding that two conditions are equivalent in effectiveness unless

power analysis (cf. Cohen 1977) has indicated a low probability of

Type II error.

INCREASING BASIC KNOWLEDGE IN THE CONTEXT OF

THERAPY OUTCOME DESIGN

Outcome research is best viewed as the experimental elucidation of the

mechanisms of the disorder being treated and of the processes of

change invoked by the treatment procedures. As such, it is in no way

different from any other scientific approach to the understanding of a

phenomenon. Therapy is an independent variable whose manipulation

will tell us something about the nature of things. The strong inference

approach–in which researchers adopt a disconfirmatory stance by

devising rival hypotheses, conducting crucial experiments in a carefully

controlled manner to rule out one or more rival explanations, and

recycling this sequence on whatever remains unrejected–is the most

effective general strategy for rapidly acquiring knowledge through the

scientific method (Platt 1964). The design options outlined earlier

represent an application of procedural strong inference to therapy

investigation. Dismantling, additive, and parametric designs provide

great power to acquire systematic and increasingly specific knowledge

about those procedures and elements of procedure causatively related

to change. Programmatic research following this strategy, thus,

inherently provides the opportunity to increase the amount of basic

knowledge about the nature of the problem and about the nature of its

change. It also yields the strongest and longest-lasting foundation

upon which to develop therapy methods that are increasingly effective.

Strong inference in outcome research is not limited only to the

systematic application of these independent variable designs, however.

Several ways exist in the context of a general outcome investigation to

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increase further the amount of basic knowledge acquired. An example

will help to clarify how this can be done. In the early 1970’s,

beginning trials on the effects of relaxation training on insomnia were

initiated based on two sets of earlier research that suggested that

(1) people with insomnia experienced autonomic hyperactivity and

(2) relaxation was effective in reducing autonomic activity. The first

controlled trial compared progressive relaxation, hypnotic relaxation,

self-relaxation, and waiting-list no-treatment conditions on daily

self-reports of latency to sleep onset. The results of this study allowed

the conclusion that relaxation was effective in reducing reported sleep

disturbance (i.e., the three relaxation groups showed superior outcome

relative to the no-treatment group). This is not a very specific

conclusion because in the absence of differences among the three

treatment conditions, the only rival explanations that could be ruled out

were history, maturation, repeated testing, and the other internal

validity threats ordinarily controlled by a no-treatment condition.

Six years later, from systematic, strong inference-based studies by

various laboratories, the following conclusion could be drawn:

Progressive relaxation is significantly effective in reducing the

subjective distress of the subjective insomniac and the subjectively and

objectively (EEG) defined distress of the psychophysiological

insomniac; of the two elements of progressive relaxation procedure

(tension-release of muscle groups and focused attention on the

resulting sensations), it is muscle tension-release that maximally yields

this effect, and reduction in cognitive intrusions at bedtime rather than

reduction in autonomic activity is the site of effect.

Both of the above conclusions say that relaxation helps insomnia, but

the latter is far more specific. It emerged from applications of strong

inference strategy to (1) the independent variable of progressive

relaxation through component control designs, (2) the dependent

variable of sleep disturbance through breaking it into subjective and

psychophysiological elements for measurement, (3) client

characteristics through empirical identification of contrasting subtypes

of people with insomnia complaints, and (4) mechanisms of change

through theoretically based hypotheses about the cognitive and

autonomic maintaining conditions of the disorder and their role as

potential sites of effect for the treatment elements. Even these

statements are only relatively true because they represent only what

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has not yet been rejected, and subsequent research will lead to even

greater specificity as further rival hypotheses generated from the

unrejected remainder arc ruled out. Notice that both basic and applied

knowledge have been increased by this history of research: researchers

know much mom about the nature of the disorder and its change and

what areas are heuristic to pursue in order to increase further the

efficacy of the treatment method, and they know that certain elements

of the original progressive relaxation technique are unimportant for the

client to learn.

Careful choice of experimental and control conditions is one way to

increase the amount of basic knowledge derived from a therapy study.

Selecting measures that assess more than just the target problem is

another way. Prior theory and empirical results about the nature of the

disorder and the nature of the therapy technique serve to guide the

selection of measures of possible client characteristics and sites of

treatment effect for evaluation from a strong inference point of view.

Each of these potentially important variables can be seen as

representing rival hypotheses. Each can be contrasted to the others, or

contrasting levels along the dimension(s) underlying any one of them

can be created. When important client characteristics are empirically

identified, subtypes representing potentially different functional

relationships can be defined, investigated in their own right, and

factored into experimental therapy designs involving the matching and

mismatching of client type with theoretically related treatment elements

along with process measures theoretically linked to each type, each

treatment element, and each hypothesized interaction of type and

element. Given the enormous cost in time and resources associated

with a therapy outcome trial, the use of such carefully selected

measures is a relatively low-cost investment with a potentially large

payoff in knowledge.

One other recommendation can be made that can serve the above

mission and contribute to the important operational definition of

clinically significant change. Comparing clients on carefully selected

measures to a sample of individuals who do not have the presenting

problem can provide correlational data that hint at potentially crucial

mechanisms of disorder and, thus, potential sites of effect for change

process. Furthermore, by acquiring data from a healthy group on all

outcome measures used in the therapy trial, the basis for establishing

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local norms for definition of high endstate functioning is laid. Strong

inference can proceed further by continuing to develop contrasting

dispositional groups to rule out crucial additional rival hypotheses.

Consider, for example, the possible controls established within a group

comparison study by the following types of contrast groups for

generalized anxiety disorder (GAD): affective disorder (to control for

the frequent depression experienced in GAD), pure obsessions (to

control for excessive, uncontrollable cognitive activity), social phobia

(to control for this most frequent additional diagnosis among GAD

clients), and any of the preceding groups (to control for the presence

of a psychological problem). The outcomes of the dispositional group

comparison, whether involving “normal” or other clinical samples,

must be viewed very cautiously, however. Many rival hypotheses exist

to explain a difference between two groups whose members were not

determined randomly. Matching the groups on variables known to

relate to the employed measures helps somewhat because matched

variables can be ruled out from explaining any differences found on

the other measures of interest. Even then, however, there are many

unknown ways in which the groups might have differed that may be

the actual cause of observed differences, and without random

assignment researchers have no basis for assuming equivalence on all

other variables.

CONCLUSION

Scientific method in any discipline, and in areas within a discipline, is

constantly evolving. New designs and methodological requirements

emerge from time to time as researchers learn more about a

phenomenon and more about the necessary conditions for being able to

draw valid conclusions from the experimental method. Because

research always is involved in the movement from what is known into

what is unknown, investigators will discover routinely that how they

went about investigating something in the past had some flaws in it,

and these discoveries will in turn lead to improved methods. The

history of therapy outcome research provides good examples of this.

For example, in retrospect, outcome research using placebo conditions

prior to the mid-1970’s was flawed by nonspecific procedures that

were later found to be inadequate for controlling for the very features

of therapy (e.g., expectancy) for which they had been created

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originally, This recognition led to the development of expectancy/

credibility assessments, greater care in the creation of therapy and

control conditions, and the ultimate demise of placebo conditions in

clinical psychosocial therapy research. Conversely, valid

measurements of therapy quality have not yet been developed, and

without such measures the possibility of confounding differences in

quality among contrasting conditions will remain a serious

methodological problem. Although this chapter suggests design

options that likely will reduce the potential confounding influence of

differential quality among conditions, final resolution will depend on

advances yet to be made in the valid and reliable measurement of

therapy quality. The present chapter has summarized and highlighted

some of the more crucial features of what currently are held to be

essential characteristics of therapy outcome investigation. Researchers

can count on changes in these requirements in the future. At the same

time, they can celebrate the significant advances in knowledge about

some forms of psychopathology and the treatments that have emerged

recently as a consequence of the application of the best scientific

methods that were available at the time.

The present paper also argues that the appropriate goal for therapy

investigation is the acquisition of basic knowledge. Thinking of

therapy as an independent variable no different from any other

independent variable and designing outcome studies whose primary

orientation is the application of strong inference methods to

independent variables, mediating variables, and dependent variables in

order to elucidate the nature of the change process and the nature of

pathology represents the very best approach for acquiring such

knowledge and, ultimately, for developing increasingly effective

techniques for treating psychological disturbance.

287
REFERENCES

Barlow, D.H. Anxiety and Its Disorders. New York: Guilford Press,

1988.

Campbell, D.T., and Stanley, J.C. Experimental and QuasiExperimental Designs for Research. Chicago: Rand McNally, 1963.

Cohen, J. Statistical Power Analysis for the Behavioral Sciences.

2d ed. New York: Academic Press, 1977.

Davison, G.C. Systematic desensitization as a counterconditioning

process. J Abnorm Psychol 73:91-99, 1968.

Howard, K.I.; Cox, W.M.; and Saunders, S.M. Attrition in substance

abuse comparative treatment research: The illusion of

randomization. In: Onken, L.S., and Blaine, J.D., eds.

Psychotherapy and Counseling in the Treatment of Drug Abuse.

National Institute on Drug Abuse Research Monograph 104. DHHS

Pub. No. (ADM)91-1722. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1990. pp. 66-79.

Lettieri, D.J. A Primer of Research Strategies in Alcoholism Treatment

Assessment. Washington, DC: U.S. Govt. Print. Off., 1992.

Moras, K. Substance abuse research: Outcome measurement

conundrums. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds.

Behavioral Treatments for Drug Abuse and Dependence. National

Institute on Drug Abuse Research Monograph 137. NIH Pub. No.

93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1993. pp. 199-214.

O’Leary, K.D., and Borkovec, T.D. Conceptual, methodological, and

ethical problems of placebo groups in psychotherapy research.

Am Psychol 33:821-830, 1978.

Paul, G.L. Insight Versus Desensitization in Psychotherapy. Stanford,

CA: Stanford University Press, 1966.

Paul, G.L. Behavior modification research: Design and tactics. In:

Franks, C.M., ed. Behavior Therapy: Appraisal and Status.

New York: McGraw-Hill, 1969. pp. 29-62.

Platt, J.R. Strong inference. Science 146:347-353, 1964.

Vallis, T.M.; Shaw, B.F.; and Dobson, K.S. The Cognitive Therapy

Scale: Psychometric properties. J Consult Clin Psychol 54:381-385,

1986.

Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, CA:

Stanford University Press, 1958.

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ACKNOWLEDGMENT

Preparation of this paper was supported in part by National Institute of

Mental Health Grant MH-39172.

AUTHOR

T.D. Borkovec, Ph.D.

Distinguished Professor of Psychology

Department of Psychology

Pennsylvania State University

417 Bruce V. Moore Building

University Park, PA 16802

289

When Clinical Trials Fail: A

Guide to Disaggregation

Kenneth I. Howard, Merton S. Krause, and John S. Lyons

INTRODUCTION

Unless all patients in an experimental treatment and none in the control

condition are cured, a clinical trial, to some degree, has failed. Such

failure, however, can be mitigated through the use of disaggregation

techniques. The present chapter discusses how the design, execution,

analysis, and interpretation of clinical trials can be enhanced through

the measurement and consideration of uncontrolled variables likely to

influence treatment outcome. Unless treatments exist that will cure all

of the people all of the time, such disaggregation provides important

mechanisms for uncovering who is likely to be helped by any given

treatment.

A spirit of orthodoxy–research correctness–has swept the land.

Investigators and critical reviewers have adopted Sir Ronald Fisher as

their prophet and his revelations in the early part of this century

(Fisher 1925, 1935) as their gospel. The clinical trial is the way to

truth; there is no other. Random assignment and power analysis are its

banner.

These thoughts are offered not in the spirit of ecumenism, for internal

and external validity can never be reconciled, but in the name of

investigatory eclecticism. A great deal of empirical knowledge has

been established without the benefit of Fisherian orthodoxy–without

the benefit of “true” experiments. It is also the case that a large

number of clinically important variables (e.g., gender, age, education,

diagnosis, chronicity, and severity of disturbance) do not lend

themselves to experimental control through random assignment. There

needs to be tolerance for different approaches to the establishment of

knowledge–tolerance for the distribution of emphasis on internal

versus external validity.

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One major issue is to find a balance between methodological rigor and

the research questions that investigators seek to answer, for it is folly

to allow methodological rigor to lead empirical inquiry to trivial

results. The fundamental and immediate goal of treatment research is

to determine to which of a specified set of treatments future patients

are to be assigned. A longer term goal is to refine the best treatments

available in order to make each treatment more nearly optimal for

patients. Ultimately, the hope is to devise a set of treatments that will

cure the target illness in all patients. This clinical goal must be kept

clearly in mind when research data are analyzed.

In a clinical trial, if one treatment is statistically significantly better

(i.e., has a higher enough mean outcome) than another, therapists are

now inclined by statistical tradition to assign all subsequent patients to

the better treatment (once they are satisfied that this is indeed a

statistically reliable finding over replications). If no treatment is

reliably significantly better than the others, they are inclined by

statistical tradition, other things (e.g., dollar costs and side effects)

being equal, to assign subsequent patients indifferently to one

treatment or the other. All of this seems quite unexceptional and is

quite logical if and only if a certain familiar and simple statistical

model holds. If all the variance in outcomes within the experimental

and control groups is error variance (i.e., due to random error in the

form of patient compliance error, treatment dosage error, and

measurement error) while the groups’ sample means are unbiased

estimators of their respective population means, then making patient

assignment decisions on the basis of mean differences is quite

justifiable. This has the great advantage of making clinical trial data

very easily and directly interpretable in terms of subsequent patient

assignment decisions and, so, very obviously satisfying the immediate

clinical purpose for conducting clinical trials. The main effects plus

random error model is, of course, the principal contributor to all of this

convenience and decisiveness. Yet, how many investigators and

therapists believe that a single treatment will be the best for all

patients? Nature seems to abhor such main effects.

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THE IDEAL CLINICAL TRIAL

In order to understand the functions of disaggregation, investigators

have to understand what an ideal clinical trial would be, because

disaggregation ought to move them closer to that ideal. The ideal

clinical trial would be a demonstration of a fully specified causal

model of a treatment and all of its clinically relevant consequences

manifested by all the different kinds of treatment settings, therapists,

and patients to be encountered in actual practice. This could be

thought of as the time course (over treatment) of points representing

single cases in an abstract space WXY, where the W are uncontrolled

variables (e.g., severity of disturbance, pattern of abuse, and vocational

stability), the X are controlled independent variables (treatment

conditions), and the Y are dependent (outcome) variables. Each point

in WX would map one-to-one on to one and only one point in Y.

Thus, in this ideal model, investigators would know the necessary and

sufficient condition for each outcome.

In the simplest case, Y could have only two locations (e.g., abstinent

and not abstinent). Y becomes more complex as the number of

outcome variables and values is increased to include such constructs as

being free of crime, living independently, and being psychologically

healthy. For clarity of example, however, assume the simplest case for

Y–one outcome variable, two values.

The simplest case of X would be two treatment conditions. X

becomes more complex as characteristics of the treatment conditions

are included (e.g., treatment integrity, therapeutic relationship, and

dosage). Again, assume the simplest case–two treatment conditions.

W contains all of the variables that were meant to be controlled

through random assignment. These are all of the possible causal

influences that interact with treatment conditions to produce a

particular outcome.

In a one-to-one mapping, all of the patients at a particular location in

W who have the same treatment have the same outcome. A many-toone mapping occurs when patients at different locations in W who

have the same treatment have the same outcome-this would allow for

aggregation over these locations in W. A one-to-many mapping means

that patients at the same location in W who have the same treatment

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have different locations in Y (different outcomes). In this case,

supplementation of the W space is called for.

Clinical trials succeed fully when and only when the experimental

treatment cures everyone and the control treatment cures no one and

this is due solely to these treatments. Theoretical expectations for each

and every patient are corroborated unambiguously by such a result and

by no other, and, except for cautionary replications, the line of

investigation as to the treatment of some pathology in some sort of

patient is finished for the time being.

Whenever a clinical trial does not succeed fully, it fails to some

degree. Anything short of total cure by the experimental treatment, of

absence of any overlap of results between the experimental treatments,

and the control treatment constitutes some degree of failure.

Disaggregation is one kind of salvage operation for such failure. Just

what kinds of patients under what kinds of conditions are cured by the

experimental treatment? By the control treatment? By both? What

kinds of patients under what kinds of conditions have what sorts of

better outcomes short of cure for the experimental treatment? For the

control treatment? For both? What confounds may be involved?

These are disaggregation issues requiring further distinctions, a

supplemented WXY space, to be addressed (Krause 1985).

Disaggregation is called for whenever this mapping is one-to-many in

one or more of the localities of the abstract WXY space (i.e., patients

in the same location in WX have different outcomes, or different

locations in Y). Disaggregation is undertaken in the hope that some

supplementation of WX, some additional independent variables, will

allow one-to-one mappings. The essence of disaggregation is adding

distinctions among cases so cases that are identical in a particular WX

(but different in Y) become distinct in a supplemented WX.

Statistical tradition has been just the opposite of such disaggregation.

It has been typified by reliance upon mean values as the best estimate

for all cases in a treatment group, forcing a one-to-one mapping from

WX to Y for each treatment group. Any underlying one-to-many

mapping is dismissed as random error, which is, of course, quite

proper when the residual variance is indeed nothing but random error.

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SIGNS OF FAILURE

In the actual implementation of a clinical trial, there are several signs

that indicate the need for disaggregation.

The Possibility of Treatment Confounds

Randomization Does Not Produce Equivalent Pretreatment

Groups. This is a very probable event. As an example, suppose that

there is a confounding variable that has only two values (present or

absent) and the probability of its presence in the population is 0.50.

Further, suppose a sample of 48 people is drawn from this population

and randomly assigned to two groups of 24 people. What is the

probability that the confounding variable has been orthogonalized? In

other words, what is the probability that each group will contain the

same number of people who have that variable (e.g., the same number

of males)? The answer is 0.115! The presence of more than one

confounding variable decreases the probability of orthogonalization

even more. One approach to this problem, if circumstances permit, is

to rerandomize until equivalence on plausible confounds is attained

before treatment is administered.

There Is Data Attrition (i.e., Some Data are Missing for Some

Subjects) During the Execution of the Study. Attrition always

compromises randomization (Howard et al. 1986, 1991), and there is

no way for correcting this without the assumption that the attrition was

random. At the very least, pretreatment equivalence should be

established for the groups actually used in the analysis of treatment

completers. Rogers and colleagues (1993) have proposed a method for

testing the equivalence of two groups that also allows for the

assessment of how different the two groups could be based on the

observed means and variances. In addition, this chapter also shows

how equivalency testing is more appropriate and informative than

power analysis.

There is a Large Amount of Within-Group Variance With Regard

to the Outcome Measure. Lyons and Howard (1991) have proposed

a statistical test to evaluate whether within-cell variance is real or

random. If within-cell variance exceeds measurement error, the F-test

is significant, and the amount of variance left unaccounted for is

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relatively large, then there are real differences in outcome among

patients who have received the same treatment.

The Distribution of the Outcome Scores Overlaps for the

Comparison Groups. Outcome overlap, as well as the presence of

treatment failures in the superior treatment, indicates the importance of

interaction effects with other independent variables (i.e., the need to

supplement the WX space). Howard and colleagues (submitted) have

shown that, in the presence of outcome overlap, comparison of means

can be quite misleading. In this previous work, they also gave a

method for converting effect sizes into probabilities similar to the

approach advocated by McGraw and Wong (1992). An effect size in

group comparisons is quantified as the difference between group means

in units of standard deviation. Since 95 percent of observations fall

between ± 1.96 standard deviations from the mean, it takes a large

mean difference to ensure that the two group distributions do not

overlap. For example, for a small effect size (0.2), the probability of a

patient in the superior group having a better outcome than a patient in

the inferior group is 0.556. Similarly, for a moderate effect size (0.5)

the probability is 0.638, while for a strong effect size (0.8) the

probability is 0.714. It takes an effect size of about 3.0 (e.g., the mean

of the treatment group is 3 standard deviations from the mean of the

control group) to be reasonably sure that the superior treatment is

better for all patients of the kind included in the trial.

The Presence of Treatment Failures in the Superior Treatment.

In addition to indicating the importance of interaction effects with

other independent variables, the presence of treatment failures in the

superior treatment indicates that, unless this is merely error variance,

some alternative treatment is desirable for these cases.

DISAGGREGATION

In the course of a clinical trial, there are various phases in which

disaggregation can be utilized: design, execution, analysis, and

interpretation. In each phase, there are rules for investigators to

follow.

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Design Rules

Space out the treatment points widely in the WX space and stage the

data collection for flexible sampling at each of these treatment points.

Investigators always are designing for salvage (disaggregation), not for

balanced full factorials. It is in this regard that a randomized clinical

trial tends to be a poorly designed quasi-experiment.

Do Not Undertake the Impossible. Investigators need to be clear

about what variables may have causal impact other than the ones under

investigation (whether these are substantively causal or sources of

measurement bias) so that there is sufficient preparation for later

disaggregation. For example, in a study of a residential program for

homeless persons with substance abuse disorders, it is important to

measure prior housing stability, vocational capacity, and family

involvement. It is likely to be less important to include variables such

as insurance coverage or body image. The thrust of this suggestion is

to supplement W (the unmanipulated, measured, possibly causal

variables) as much as sensibly possible as to the number of variables,

their ranges, the density of variables’ scales, and number of subjects.

Use Multistage Sampling. When one-to-many mappings are

encountered, investigators should augment the sampling of that

treatment or locale in the X (the manipulated independent variable

space) so that there will be sufficient sample size to investigate the

efficacy of other potential causal variables (W) and to allow them to

have accumulated the coverage of their full range in order to manifest

themselves significantly. In other words, try to avoid attenuation of

correlation due to restriction of range and try to avoid insignificance of

correlation due to small sample size.

Execution Rules

Sequentially and Widely Sample, Adjusting Sampling Fractions.

As results from the study become available, adjust sampling to ensure

sufficient density at promising points in WXY.

Maintain Full Information on Each Case. A case is a unique point

in the supplemented WXY space, so the lack of information on even

one variable makes it impossible to define a unique location. Thus,

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any loss of supplemental information is equivalent to losing the case

itself.

Sample W and X (Manipulated Variables such as Treatments)

Widely. This is to allow main effects to manifest themselves strongly

and to detect interactions (i.e., local one-to-many mappings in the

original WXY space). More subjects always are better than fewer for

purposes of disaggregation. It is desirable to have to have at least 10

subjects for each disaggregation variable, but even one subject is

instructive.

Replicate at Each Point in the Supplemented WXY Space.

Without such replication, there will be no way to estimate residual

variance. In other words, there will be no way to allow one-to-many

mappings to manifest themselves and thus no way to know whether or

not the model is still underspecified. Residual error estimates have to

be made at each WXY point (locale); it remains to be determined later

whether or not it is appropriate to pool them.

Analysis Rules

Analyze, Analyze, Analyze, Test Next Time. Diverse and thorough

analysis of results provide information for further studies. Do not

depend exclusively on statistical significance.

Assess High-Priority Alternative Hypotheses. As a first check on

treatment confounds, investigators should measure what the treatment

confounds could be contributing.

Do All the WX to Y Mappings Possible in the Data. This will

enable investigators to capture more plausible explanatory hypotheses.

Investigators also can define clinical responders versus nonresponders,

establish the reliability of this distinction, and then look for factors in

which these two groups differ. In this way, it is possible to begin to

form exclusion and inclusion criteria with regard to the circumstances

under which the treatment is most appropriate and efficacious.

Research is expensive (in monetary and human terms), so investigators

cannot afford to disregard any information that might lead to the

optimization of treatment assignment. These analyses should be done

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in stages while data collection is proceeding so the preliminary results

can be used to guide further data collection.

Estimate the Best Aggregations. Wherever the mappings are

one-to-one in the original WXY space, the distinctions implied by

supplementary variables are unnecessary–this elimination (ignoring)

of unnecessary variables in a locale is the essence of aggregation.

Interpretation Rules

Speak softly in drawing conclusions and carry in mind that the fully

specified model may be much larger and different than the one

assumed in the design of a particular experiment.

Do Not Assume That There are No WX Errors (e.g., That the

Actual Location in WX Is Not Where It Was Planned To Be) and

Do Not Assume Random Error of Y. Instances of one-to-many

mappings must be presumed to contain information about either an

apparent WX location really being a different location or the presence

of confounds (i.e., the need to supplement WX).

Do Not Interpret a Regional Sample as a Comprehensive

Sample. Investigators should carefully qualify any findings with

regard to where they appear in the supplemented WX space.

CONCLUSION

Post hoc analyses take several forms and should be planned from the

beginning of the study. There are three types of variables that have

proven useful in disaggregation:

1. Input variables (W)–patient, therapist, treatment, and site

characteristics;

2. Process variables (X)–technical procedures, therapeutic

relationship, and treatment (integrity and dosage); and

3. Outcome variables (Y)–effectiveness and efficiency.

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These variables can be processed through the SAS Rsquare program

(SAS Institute 1985). This program finds the best predictor, the best

two predictors, the best three predictors, and so forth. Of course, any

result would have to be replicated, but this program generates all of

the alternative hypotheses available in the data. It will be through the

specification of the combination of these kinds of variables with

specific treatments that therapists will be able finally to determine to

which of a specified set of treatments future patients are to be

assigned.

A clinical trial must be flexible rather than predesigned completely,

and it must be designed for optimum salvage. The process of doing a

clinical trial is one of dynamic responsive redesign, not adherence to a

rigid a priori design. Orthogonality is secondary to full specification

for cures (i.e., to a particular regional completeness of WXY).

Establishing the average superiority of the experimental group is

secondary to getting some cures for further study in order to get full

specification for them.

It seems that reliance on the clinical trial has always been somewhat

tongue-in-cheek. After all, if investigators were to do clinical trials by

the standards of the prevailing statistical tradition (not those proposed

in this chapter), there would be nothing to discuss. They merely

would report the significance of the difference between means and the

effect size of the main contrasts. In fact, as Lyons and Howard (1991)

have indicated elsewhere, investigators always move on to a variety of

secondary analyses regardless of the outcome of the major

comparisons. Often this is motivated by execution difficulties such as

attrition, but these secondary analyses also seem to be motivated by a

genuine desire to discover other causal influences on the outcome of

the treatment. After all, confounds are not a nuisance; they are

plausibly efficacious independent variables whose influence should be

assessed in any attempt to find fully specified causal models that will

lead to optimal treatment assignment.

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REFERENCES

Fisher, R.A. Statistical Methods for Research Workers. London: Oliver

and Boyd, 1925.

Fisher, R.A. The Design of Experiments. London: Oliver and Boyd,

1935.

Howard, K.I.; Cox, C.M.; and Saunders, S.M. Attrition in substance

abuse comparative treatment research: The illusion of

randomization. In: Onken, L.S., and Blaine, J.D., eds.

Psychotherapy and Counseling in the Treatment of Drug Abuse.

National Institute on Drug Abuse Research Monograph 104. DHHS

Pub. No. (ADM)91-1722. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1991. pp. 66-79.

Howard, K.I.; Krause, M.S.; and Orlinsky, D.E. The attrition dilemma:

Towards a new strategy for psychotherapy research. J Consult Clin

Psychol 54:106-l10, 1986.

Howard, K.I.; Krause, M.S.; and Vessey, J.T. Analysis of clinical trial

data: The problem of outcome overlap. Psychother Res, submitted.

Krause, M.S. “The Aggregation of Data.” Paper presented at the

Department of Psychology, University of Illinois, Chicago, February

1, 1985.

Lyons, J., and Howard, K.I. Main effects analysis in clinical research:

Statistical guidelines for disaggregating treatment groups. J Consult

Clin Psychol 59:745-748, 1991.

McGraw, K.O., and Wong, S.P. A common language effect size

statistic. Psychol Bull 111:361-365, 1992.

Rogers, J.; Howard, K.I.; and Vessey, J. Using significance tests to

establish equivalence between two experimental groups. Psychol

Bull 113:553-565, 1993.

SAS Institute. The Rsquare procedure. In: SAS User’s Guide: Statistics,

Version 5 Edition. Cary, NC: SAS Institute, Inc., 1985. pp.

711-724.

ACKNOWLEDGMENT

This work was partially supported by grants RO 1 MH 42901 and 1

K05 MH 00924 from the National Institute of Mental Health.

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AUTHORS

Kenneth I. Howard, Ph.D.

Professor of Psychology

Merton S. Krause, Ph.D.

Visiting Scholar

Department of Psychology

Northwestern University

Evanston, IL 60208

John S. Lyons, Ph.D.

Associate Professor of Psychology

Department of Psychiatry and Behavioral Sciences

Northwestern University Medical School

Chicago, IL 60611

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Behavioral Treatments for Drug

Problems: Where Do We Go

From Here?

William R. Miller

INTRODUCTION

When I was invited to serve as the discussant for this technical review,

I was asked to attune my ear, which is accustomed to alcoholism

treatment research, and comment on what I heard from an outsider’s

perspective. After listening to these 2 days of papers, I feel not at all

like an outsider, for there are many familiar issues and problems for

me here.

COMMONALITIES IN ADDICTIVE BEHAVIORS

Obviously, there are many overlaps between alcohol and other drug

abuse. Our clients, in fact, do not seem to realize that there are two

separate Institutes. We treat and study substantially overlapping

populations. It is rare these days to find a client who has problems

only with alcohol, and we have heard here that perhaps half of

methadone-maintained people have active drinking problems. Relapse

is a familiar phenomenon to us all (as Dr. Marlatt’s writings have

emphasized), as is the issue of impaired control of behavior. The

etiology of alcohol and other drug problems is clearly complex,

involving biological, psychological, and social factors and (some of us

would add) spiritual dimensions. The papers presented here suggest,

not surprisingly, that the general treatment strategies that work well

with drug problems resemble those with demonstrated efficacy for

alcohol problems. We even seem to make the same mistakes in

treatment and research.

I had rather hoped to find that the treatment of drug abuse is less

mired in a dispositional disease model, but I see the same wide gap

between science and practice that has plagued the alcohol field. The

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popular disease model posits that addicts (or alcoholics) are

qualitatively different from normal human beings, not only in their

behavior but in genetics, physiology, and character, and that this is

why they have the problems they do. In this way, the dispositional

disease model is oddly like the moral model that creates “them” and

“us.” In a recent dissertation in our lab, Moyers (1991) studied the

factor structure of treatment providers’ beliefs about alcoholism; she

found a robust first factor reflecting all of the traditional beliefs of the

disease model. The moralistic items included on the questionnaire

(e.g., “Alcoholics are liars and cannot be trusted’) also loaded on this

primary factor, as did characterologic attributions. The essence of the

factor seemed to be that alcoholics are all like each other but

different–biologically, genetically, morally, and characterologically–

from normal human beings.

The papers presented here, in contrast, suggest that drug abusers are

fundamentally like other people except that they use drugs and suffer

the consequences. This is the same picture that emerges with alcohol.

“Alcoholics” are as unique and different from one another as

snowflakes. No replicable prealcoholic personality has been found

after half a century of searching for it (e.g., Vaillant 1983), and

behavioral precursors are limited to the same childhood conduct and

school problems that are related to drug abuse more generally (Miller

and Brown 1991). People with alcohol and other drug problems do

not respond any more favorably to being confronted than do the rest of

us (Miller et al., in press).

DRUG USE AS BEHAVIOR

Another familiar picture from this conference is that drug use-even

with supposedly “out of control” drugs and people–responds to

operant contingencies. This was demonstrated in the early 1970s with

alcoholics (for a review, see Heather and Robertson 1981). Drug use

is, first and foremost, behavior, shaped by and responsive to principles

of learning such as reinforcement, punishment, classical conditioning,

and modeling. This is one of the messages that I seek to convey to

psychologists and other mental health professionals: “Alcohol and

drug abusers are not Martians, governed by different laws of behavior

and requiring referral only to an initiated inner circle of experts with

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unique knowledge and techniques. Everything that you have learned

in your training is directly applicable because use is behavior, and

users are people like everyone else.” In 10 years, I hope, this

statement will be seen as an uninformative and obvious observation.

Today, in the United States, it remains embarrassingly controversial.

A common behavioral strategy for which I have heard many

applications here is successive approximation. Dr. Grabowski

advocated reinforcing successive reductions in drug use, and Dr.

Marlatt pointed out, in arguing for a harm reduction perspective, that

steps in the right direction are just that. Dr. Schuster also reinforced

this point: if an addict gives up shooting heroin, prostitution, crime,

and smoking crack cocaine but continues to use marijuana, both the

individual and society benefit nonetheless. Again, one hopes that

readers in 10 years will ask how anyone could not see this. In a recent

article (Miller and Page 1991), we described a variety of “warmturkey” alternatives for clients unwilling to accept immediate,

permanent, cold-turkey abstention. These include a trial period of

abstinence (sobriety sampling), gradual fading of dosage toward

abstinence, or a trial span of moderation to reduce or eliminate

problems and dependence. In a long-term followup study (Miller et al.

1992), we found that drinkers treated with a goal of moderation more

often opted, in the long run, for abstinence-about twice as often, in

fact, as those maintaining problem-free drinking. Even though the

practitioner’s ultimate goal for the client may be abstinence, insisting

on immediate, total, and permanent abstention from all psychoactive

drugs is not necessarily the most effective way to achieve that goal. In

a way, this has been acknowledged more readily in drug abuse

treatment (e.g., methadone and nicotine substitution) than in alcoholism

treatment. One speaker here did advocate excluding from treatment

those clients who say they want only a drug holiday–a view at odds

with a harm reduction approach that provides people with whatever

treatment and degree of improvement they are ready to accept. Such

flexibility in treatment goals may lead to better retention and improved

outcomes (Sanchez-Craig and Lei 1986).

Several examples were provided here that behaviors commonly

believed to be nearly intractable or to lie beyond the person’s

conscious control behave as operants and respond to reinforcement

contingencies: cocaine use, illicit drug use to supplement methadone,

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and the parasuicidal and therapy-disrupting behavior of borderline

patients. In Dr. Higgins’ data, I saw a suggestion that the community

reinforcement approach was less successful with those who might be

judged to have the most impaired control: daily, heavy cocaine users.

Perhaps we will find parameters of drug use that predict differential

modifiability by operant and volitional efforts (cf., Miller and Brown

1991).

It is likewise clear that the social environment more generally exerts

strong influence on drug use. Dr. Higgins reported that employment

and spouse involvement–two longstanding predictors of alcohol

outcomes–were prognostic of cocaine outcomes as well. Dr.

Henggeler provided a causal model in which neighborhood and peers

exert separate and direct effects on the likelihood of adolescent drug

use. Clearly, we should not underestimate the “social” in

“psychosocial.”

Skill training strategies, as I indicated in my review, have accounted

for at least half of the treatment methods with demonstrated efficacy

for alcohol problems. Here I note the findings of Dr. Childress that

active, not passive, coping strategies reduced craving. Dr. Higgins’

encouraging success with the community reinforcement approach,

which relies heavily on skill training, mirrors its reported strong effects

with alcohol abuse and dependence.

BEHAVIORAL INTERVENTION RESEARCH

Although the National Institute on Drug Abuse (NIDA) and National

Institute on Alcohol Abuse and Alcoholism (NIAAA) have sponsored

both biomedical and psychosocial intervention research, I am struck by

the seemingly different patterns that have arisen–surely from

historical and political factors rather than from inherent differences in

our populations. In prevention research, the alcohol field has

emphasized “the quest for the test”–the search for pathognomonic

biological factors that differentiate alcoholics from normal people. The

preventive implications of this approach are limited at best, implying a

program of identification and exhortation of alcoholics possessing the

tainted gene or physiology. NIDA, in contrast, seems to have

emphasized, to the dismay of some researchers, a supply-and-demand

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reduction approach that relies on interdiction and psychosocial

strategies. The idea of limiting the supply of (or access to) alcohol in

our society, however, is difficult to sell to legislators, and the

Norwegian Government’s official slogan, “Drink less alcohol,” seems

as alien here as goat cheese.

When it comes to treatment, oddly enough, the roles have been

reversed. NIDA has invested heavily in biomedical interventions for

addicts, as shown by the proposed inauguration of a new $65 million

initiative for medication development. The occasion of this conference

witnesses a new interest at NIDA in strengthening behavioral treatment

research. At NIAAA, behavioral treatment research has a long and

strong history, and psychosocial and biomedical studies share roughly

equal proportions of the research budget. It was in a 1990 program

announcement that NIAAA solicited new pharmacologic trials for

alcoholism treatment.

Again, we are dealing with heavily overlapping populations. In

treatment studies in our center, we now routinely include other drug

use in our outcome measures. Alcohol use is obviously a significant

factor in drug abuse treatment and trials. It is time, I believe, to

explore how NIDA and NIAAA can cooperate in facilitating,

coordinating, and funding treatment trials that increasingly bridge the

missions of these Institutes. It is time to develop consensus state-ofthe-art followup measures for alcohol and other drug use, the central

dependent variables of our research. There are also many common

issues in assessment methodology. Urine testing represents a gold

standard in drug use assessment, a technology for which there is as yet

no good parallel to verify recent drinking. Consequently, alcohol

treatment researchers have refined other methods for corroborating

client self-reports–particularly collateral interviews, which have

received curiously little attention in drug abuse treatment studies. It

remains to be seen how well the reports of significant others might

serve to verify use or nonuse of cocaine, heroin, or marijuana, for

example. The validity of collateral reports may vary from drug to

drug. Heroin use, for example, is not as likely to be observed by

nonusing spouses, and its effects may be harder to detect. Cocaine

runs, as Dr. Higgins commented, have more obvious effects observable

by significant others. Marijuana use may be more readily observed

directly by others. Collateral reports could serve as a further check on

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self-report, particularly in light of the known false positive rate (for

recent drug use) inherent in urine testing due to residual traces of prior

use. NIDA and NIAAA researchers face similar assessment problems

and could work profitably together to forge common treatment

outcome measurement strategies. The growing awareness of

multidiagnosis cases suggests that similar interface with the National

Institute of Mental Health (NIMH) is overdue, and it is likely that

quality alcohol and drug assessment will be of equal importance to

research in other parts of the National Institutes of Health (NIH).

The reasons for joint measurement of alcohol and other drug

dimensions are not limited to assessment concerns. Dr. Higgins

reported that disulfiram, in essence, constitutes an effective treatment

for cocaine use, specifically among those who also drink heavily. A

cocaine relapse may begin with drinking alcohol, suggesting a new

meaning for the concept of “gateway” drugs. Similar attention should

be paid to tobacco use, which is being explored in current NIAAA

research as a correlate of alcohol use and relapse. Suppression of only

one drug, without paying attention to the impact on and effects of

other drug use, makes little sense in a population in which polydrug

abuse is normative.

Further, research should seek to disaggregate the effects of treatment

modalities from settings. Residential and inpatient treatment have

consumed the lion’s share of treatment dollars, despite the fact that

nearly every literature review of the past two decades has concluded

that such settings offer no overall benefit above that afforded by

outpatient treatment (Annis 1985; Kiesler 1982; Miller and Hester

1986; U.S. Congress 1983). If a specifiable subgroup does benefit

differentially from more intensive and expensive care (a sensible

possibility), this remains to be demonstrated, and the characteristics of

this group should be documented and replicated.

Treatment process also deserves much greater attention.

Dr. Borkovec’s call for research to delve deeply into treatment

processes is well taken. Careful process research can help us

understand how and why change occurs and elucidate the nature of the

very problems we are treating. Yet, such depth is not logically

precluded in comparative clinical trials. It is possible to study two or

more treatments deeply and simultaneously, gaining both process and

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relative outcome knowledge. The comparison of different strategies is,

I believe, entirely appropriate at this stage of knowledge development.

The “horse race” pejorative unfairly oversimplifies the modem welldesigned clinical trial. New insights into the nature of a disorder can

arise from main effects and interaction (matching) effects as well as

from the same within-treatment analyses that are possible in a singletreatment study. The randomized trial also provides a level of causal

inference not achieved readily through other designs. “Comparative”

and “depth” are not alternative designs but different possible aspects

within designs. Like process and outcome, both types of knowledge

can be obtained from a well-designed trial.

Dr. Howard also was eager to hobble and humble randomized trials, or

at least, by polemic attack, to inspire a defensive improvement in

them. I surely favor the latter goal, and the methodologic criticisms he

raised are worthy considerations, but they are worries for which

remedies already exist. His concern that randomization can result in

nonequivalent groups on critical pretreatment variables is mitigated in

larger samples, and it can be addressed by a variety of methods for

ensuring balance while retaining essential randomization such as

L.J. Wei’s (1978) urn randomization procedure. The problem of data

attrition is not unique to randomized trials, but, as several presenters

here have shown, there are various effective ways to improve the

retention of subjects in treatment and research. Dr. Howard’s worry

that the distributions of experimental and control groups may overlap

is real enough, but it is not properly solved by eliminating the control

group from one’s design! Noncomparative designs simply ignore the

problem of relative outcomes. Having reviewed the alcoholism

outcome literature over the past two decades, it is my experience that

the relative contrasts of comparative trials yield a much more

consistent picture across replications than do uncontrolled trials

(cf., Holder et al. 1991; Miller and Hester 1980).

At the same time, I hasten to agree that randomized trials are not

always the most appropriate method for generating new knowledge

about treatment. Consider, for example, the need for new research

with Alcoholics Anonymous (AA) and other 12-step groups, a priority

highlighted by the National Academy of Sciences (1989). Twelve-step

group participation is too often regarded by researchers as a nuisance

variable to be minimized. Yet, the vast majority of alcohol and drug

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treatment programs in the United States espouse a 12-step philosophy

and commend or require group attendance, and the 12-step fellowships

serve far more individuals every year than do all treatment efforts

combined. What happens to people over a course of involvement in

such groups? Why do some stay and others fail to return? What

attracts people to 12-step fellowships? How, when, and for whom

does change occur? These and many other questions can be answered

by research (McCrady and Miller, in press), but the 12-step groups do

not readily lend themselves to randomized trials because of their

ubiquity. Incidentally, contrary to statements made here, there is no

official institutionalized resistance to research in AA. To the contrary,

Bill Wilson wrote a memorandum encouraging AA members to

participate in scientific research that continues to be circulated by the

AA central offices. My point though, for which this is but an

illustration, is that there are behavioral outcome questions for which

designs other than randomized trials are optimal. Both types of

research are needed.

On the issue of studying heterogeneous versus homogeneous samples,

again it depends upon one’s purpose. In seeking to discover client-bytreatment matching interactions, it is essential to start with a sample

that is heterogeneous with regard to the predictor variables. Recent

Federal requirements to represent females and minority groups in study

samples whenever feasible also favor heterogeneity. The limiting of a

treatment study to a homogeneous sample may be warranted once there

is already persuasive evidence that the intervention(s) under study will

be differentially appropriate for that subsample. We have little such

knowledge regarding drug abusers. Had the NIMH collaborative trial

been limited to “exogenous” depression, for example, the field would

have been deprived of the important information that “endogenous”

depression responds comparably to pharmacotherapy and cognitive

therapy–a finding that in itself raises questions about the exogenous/

endogenous distinction and related etiologic assumptions.

IMPROVING TREATMENT

With regard to improving treatment, it is clear from the presentations

made here that retention and compliance are crucial issues in treating

drug problems in general as they are with alcohol problems in

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particular. People who stay in treatment longer, follow advice, do

homework assignments, and practice active coping strategies are

generally found to fare better at followups. The tendency in this field

is to regard these as the “good” patients and to blame attrition and

noncompliance on poor client motivation or character. There are

persuasive reasons, however, to reevaluate this view. We have argued

elsewhere that motivation, denial, and compliance are not client

problems but therapist and program problems (Miller and Rollnrick

1991). Dr. Higgins showed us data in which treatment retention varied

from 11 percent to 93 percent across groups in randomized trials.

Therapist behaviors have been shown to be strong predictors of client

dropout, resistance, progress, and outcome (McLellan et al. 1988;

Miller and Rollnick 1991). Dr. Linehan described for us a treatment

program that has retained 80 percent of its borderline patients for one

year, an impressive achievement with a population usually assumed to

be characterologically incapable of sustaining treatment. If the

characteristics of therapists and programs determine the rates of client

retention and compliance, which in turn drive treatment outcomes, high

priority ought to be given to identifying those characteristics and to

learning how to train and influence them. As Dr. Grabowski observed,

all treatment programs stand somewhere on these characteristics

(contingencies) and, thus, are already influencing client behavior in

crucial ways, for better or worse.

This, in turn, raises for me some reservations about selecting research

subjects on the basis of their “wanting” or “willingness” for particular

treatment(s). The willingness to accept disulfiram, for example, has

been used as an inclusion criterion for clinical trials (e.g., Azrin et al.

1982; Fuller et al. 1986). Yet, if client willingness (motivation) is so

susceptible to influence, we need, at the very least, to specify the

procedures used to “sell” interventions to potential subjects–an aspect

of research procedure often unmentioned in proposals and reports.

These procedures will, in turn, impact recruitment rates, sample

characteristics, external validity and replicability, and human research

review considerations. Here is another area for study!

I believe that there is a real opportunity now to improve treatment by

inculcating evaluation values in local programs. One way to do this is

by tightening up accountability for program (or therapist) outcomes,

and the Joint Commission on Accreditation of Healthcare

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Organizations is already taking steps in this direction. The astounding

lack of accountability in this field for using research-supported

treatments needs to be remedied.

At least as important, however, is encouraging and empowering

treatment programs and professionals to evaluate their own work as a

method for obtaining feedback and improving practice. Learning does

not occur without feedback; yet, most practitioners work in a nearly

total feedback vacuum, receiving little or no useful information to help

them become more effective. Apparently, this problem is recognized

by clinicians. Dr. Schuster reported here that, in a survey of drug

abuse practitioners, the need for help in program evaluation was placed

at the top of a wish list. It is possible to promote excitement and

expertise for program staff by having them engage in evaluation

studies, which need not be large-scale time-intensive trials. Relatively

simple studies of immediate practical importance can be conducted in

ongoing care delivery settings (e.g., Chafetz 1968).

How might this be accomplished? Develop intriguing do-it-yourself

research workshops for program staff, and market and deliver them on

a national scale. Find ways to reward staff and programs for

evaluation that go beyond the documentation of effort and

demographics. Encourage replications of promising treatment methods

at the local level. Dr. Higgins pointed out the importance of

evaluating new methods in one’s own clinic to fine tune them and

determine how and for whom they work. Contracts for such onsite

replications in clinical settings could be offered through special

programs in NIDA or the Center for Substance Abuse Treatment

(CSAT). Regional continuing education events could provide training

on how to conduct program evaluation at the local level with ample

opportunities for input and ideas from participants.

Significant progress also might be accomplished through training and

research centers. A predoctoral National Research Service Award at

our center has had this effect as an originally unforeseen side effect of

training. Six trainees per year have been placed in community

treatment and prevention programs with the sole focus of helping staff

conduct program evaluation research. Rather than bringing

preconceived projects with them, these trainees typically have

interviewed program staff to ask what questions would be of particular

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importance and interest to them. Studies then are designed to meet

these needs, with the trainee serving as a free consultant. Over the

first 5 years of this training program, we have developed not only

trainees but also a number of community program research sites that

now compete with each other for trainees. Publishable research has

emerged from several sites, which also has had immediate practical

importance for the sites. Treatment training and research centers could

be asked to propose plans for community training and dissemination

efforts in new and renewal proposals.

At the same time, as Dr. Moras discussed, we need to strengthen

treatment research methodology. There is a wealth of know-how

scattered among investigators with regard to the usually undiscussed

but critical aspects of how to conduct research: selecting and training

personnel; recruiting and retaining samples; collecting, entering, and

cleaning data; conducting interviews; instrumentation; and other

aspects. Examples of this know-how have been shared at this meeting.

It is time to gather some of this accumulated wisdom together and

make it accessible to new and current researchers before those who

possess it are lost to retirement, burnout, or other fields. Special

attention and development should be devoted to evaluation procedures

that can be implemented in local program settings.

KNOWLEDGE DISSEMINATION

I have elsewhere bemoaned the immense gap that exists between

practice and research in the alcohol field and suggested some possible

causes and remedies (Miller 1987). This gap is, I believe, one of the

most significant problems in the field of alcohol and drug abuse. The

move of our Institutes to NIH could worsen this gap, separating the

research institutes further from the primary Federal program

mechanisms of CSAT, the Center for Substance Abuse Prevention

(CSAP), and the block grants. The fault does not lie clearly on either

side, and there is much we can do as researchers to help bridge the

gap. In order for research findings to be implemented in practice, for

example, it is essential to do far more than publish them in scientific

journals. A broad range of practitioners must be informed, motivated,

trained, and empowered to implement the new technology. There are

models already available (e.g., drug companies), and we could draw

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upon the expertise of those who specialize in knowledge dissemination

and technology transfer. Let me suggest just a few ideas.

1.

2.

3.

4.

Make knowledge and technology accessible to practitioners. Few

clinicians (and, for that matter, few researchers) are likely even to

read a particular article in a scientific journal. Research needs to

be made available, interesting, and comprehensible to service

providers. This means publishing in the periodicals that

practitioners read, attending and presenting at popular clinical

conferences, and working with professional organizations. The

more practical the material, the better. Therapist manuals, as they

are developed in research, can be reviewed and published for

general use, and they are likely to be consumed eagerly. Self-help

materials might be generated from some technologies and tested in

separate studies. National and regional training (preferably free)

could be offered in the newest clinical methods to emerge from

research as an alternative to the tired recapitulations of unproven

lore that currently characterize most substance abuse professional

meetings.

Market new knowledge and technologies in ways that speak to the

perceived needs and problems of clinicians. People are motivated

to change when they: (a) perceive a significant problem or

opportunity and (b) perceive an effective solution that is possible

for them to implement (Rogers and Mewborn 1976). The striking

popularity of “relapse prevention” training is a case in point:

substance abuse clinicians recognize the problem of relapse and are

searching for effective ways to address it.

Provide a carefully edited information resource for practitioners.

The Prevention Pipeline and Brown University’s Digest of

Addiction Theory and Application are examples of such efforts,

though both are broader and contain little practical knowledge.

The Journal of Substance Abuse Treatment has this potential, but

most of the material it presents is lacking in a research base.

Require potential grantees to include, as part of an application for

research or training funds, a plan for dissemination of research

findings to be reviewed with the proposal. This would heighten

attention to this issue and draw on the creativity of researchers to

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address it. Alternatively, researchers with meritorious and

applicable findings could be encouraged to apply for separate

Phase II dissemination funding by proposing such a plan.

Dissemination phase funding of this kind is already represented in

the prevention programs of the U.S. Department of Education’s

Fund for the Improvement of Post-Secondary Education and in

Phase II review for Small Business Innovation Research grants.

Still another possibility is for independent contractors to propose

plans for disseminating an Institute’s significant clinical findings to

the practice field.

5. Create two-way research and practice partnerships. To the extent

that service delivery programs can be recruited as partners with

researchers through the training efforts described earlier, channels

are created through which knowledge dissemination in both

directions is possible. Mechanisms for the formation of such

partnerships could be developed. Again, investigators and centers

applying for funding, particularly programmatic funding, could be

asked to propose ways in which they will interact with their

communities to establish such relationships with service providers.

It is our experience that these are long-range efforts in which

significant fruit is borne over the span of a decade or more.

A CONTINUUM OF INTERVENTIONS

Finally, I would offer the challenge of fully recognizing and

implementing in the drug abuse field the National Academy of

Sciences’ (1990) perspective that the problems we address lie along a

continuum. In fact, it appears that there are a number of loosely

interrelated continua of severity, including: (1) use, (2) life problems,

(3) dependence, (4) biomedical sequelae, (5) neuropsychological

impairment, and (6) other quality-of-life factors. In the drug abuse

treatment field, as in the treatment of alcohol problems, the bulk of

intervention efforts and funding have been concentrated on the tip of

the triangle. As one proceeds away from this tip, the base broadens,

and one encounters ever larger numbers of people with less severe but

nevertheless significant problems. The use of binary diagnosis has

supported the notion that those above a certain severity cutoff point

require intervention and those below it do not.

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A continuum of interventions can be conceived, ranging from primary

prevention to intensive treatment (National Academy of Sciences

1990). It has been the “middle classes” of the severity triangle who

have received the least attention. Primary prevention and intensive

treatment both are offered widely. The former is insufficient and the

latter too heroic for those with midrange severity. In the alcohol field

these are the problem drinkers and risky drinkers, whose behavior is

already worrisome and who account for the majority of alcohol

problems in society (Moore and Gerstein 1981), but who do not

evidence the deterioration and dependence that treatment programs

usually are designed to address. Many such individuals are currently

identified through employee assistance programs (EAPs) and arrests for

impaired driving. They are left, typically, to choose between diseasemodel treatment or no treatment at all. It is here that brief

interventions and behavioral self-control training have shown the

greatest promise, producing consistent improvement with individuals in

the mild-to-moderate severity range.

NIDA faces a similar challenge. Drs. Higgins and Grabowski both

presented data indicating that those who are less impaired at intake

fare better in treatment-an argument for still earlier outreach.

Dr. Marlatt appealed for brief services on a harm reduction model

through which contact can be established with a broader range of drug

abusers. The rapid growth of drug testing is already turning up a

substantial number of drug users with low severity of use, problems,

and dependence, many of whom are employed and functioning well.

As drug-testing practices spread, this number will continue to grow.

What is to be done with and for these less severe users? They are

unlikely to respond well to being told that they have the primary

disease of chemical dependency, confronted in group psychotherapy,

sent to hospitals or 12-step groups, and instructed to abstain from all

licit and illicit psychoactive drugs for life. A harm-reduction

perspective holds that less use is better than more use and that fewer

problems and risks represent an improvement. Politics run high here,

particularly in a zero-tolerance atmosphere, because illegal substances

are part of the picture. Behavioral interventions with demonstrated

efficacy for problem drinkers that are logically generalizable to other

drug problems do exist. Behavioral self-control training, for example,

has a strong track record in reducing alcohol use (Holder et al. 1991)

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and already has been applied with polydrug users (Wilkinson and

LeBreton 1986). Initial trials indicate that motivational interviewing

and a “drinker’s check-up” suppress alcohol use in midseverity

drinkers (Miller et al. 1988, in press) and increase responsiveness to

treatment (Bien 1991; Brown and Miller, in press). Other researchers

have applied this approach in addressing heroin use (Saunders et al.

1991; Van Bilsen 1991). The alcohol field has long struggled with

how to serve the midrange severity population who seem to require

less intensive treatment and greater goal flexibility, How will the drug

abuse field respond?

Perhaps it will be economics that, in the long run, forces a response.

While EAPs, courts, and drug testing provide an ever-growing base of

clients for treatment, public funding for services continues to wane.

The result, like it or not, will be briefer, less-intensive interventions for

many. This is not necessarily a negative outcome. Dr. Grabowski

reported here that less frequent visits increased patient retention in

treatment, while the requirement of more visits after positive drug tests

tended to elevate the relapse rate. Dr. Stitzer listed less frequent

counseling as a reinforcer for clients! In the alcohol field, few

differences have been found in the efficacy of inpatient versus

outpatient or brief versus extended treatment (Bien et al., in press).

Deaton and Olbrisch (1987) have proposed, tongue-in-cheek, that

brevity of contact with therapists is the active ingredient in treatment

effectiveness. For certain therapists, at least, it appears that less

contact is indeed better (McLellan et al. 1988; Miller et al. 1980).

The brighter side of this picture is that brief, well-conceived treatment

appears to be at least as effective as traditional intervention for many

people, particularly those with less severe problems. This makes it

possible to provide services to a broader range of clients. It is an

unanswered question whether and which people, failing to remit with

brief intervention, will benefit differentially from additional treatment.

In any event, the development of midrange interventions for less

severe drug abusers remains important uncharted territory. The

realities of increasing demand and decreasing funding for treatment

leave us with two options: continue trying to provide ever-diluted

treatment in the traditional model or develop a well-planned system in

which different levels and types of intervention are provided to people

based on their needs and characteristics.

317
I am grateful for the privilege of reflecting on the proceedings of this

interesting conference, and I look forward to the fruit this meeting may

bear in the years ahead.

REFERENCES

Annis, H.M. Is inpatient rehabilitation of the alcoholic cost effective?

Con position. Adv Alcohol Subst Abuse 5(1-2): 175-5190, 1985.

Azrin, N.H.; Sisson, R.W.; Meyers, R.; and Godley, M. Alcoholism

treatment by disulfiram and community reinforcement therapy.

Behav Res Ther 14:339-348, 1982.

Bien, T.H. “Motivational Intervention With Alcohol Outpatients.”

Ph.D. diss., The University of New Mexico, 1991.

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for

alcohol problems: A review. Addiction, in press.

Brown, J.M., and Miller, W.R. Impact of motivational interviewing on

participation and outcome in residential alcoholism treatment.

Psychol Addict Behav, in press.

Chafetz M.E. Research in the alcohol clinic of an around-the-clock

psychiatric service of the Massachusetts General Hospital.

Am J Psychiatry 124:1674-1679, 1968.

Deaton, A.V., and Olbrisch, M.E. The effective ingredient in

psychotherapy: An alternative to the spontaneous remission

hypothesis. In: Ellenbogen, G.C., ed. Oral Sadism and the

Vegetarian Personality. New York: Ballantine Books, 1987.

Fuller, R.K.; Branchey, L.; Brightwell, D.R.; Detman, R.M.; Emrick,

C.D.; Iber, F.L.; James, K.E.; Lacoursiere, R.B.; Lee, K.K.;

Lowenstam, I.; Maany, I.; Neiderheiser, D.; Nocks, J.J.; and Shaw,

S. Disulfiram treatment of alcoholism: A Veterans Administration

cooperative study. J Nerv Ment Dis 256:1449-1455, 1986.

Heather, N., and Robertson, I. Controlled Drinking. London: Methuen,

1981.

Holder, H.; Longabaugh, R.; Miller, W.R.; and Rubonis, A.V. The cost

effectiveness of treatment for alcoholism: A first approximation.

J Stud Alcohol 52:517-540, 1991.

Kiesler, C.A. Mental hospitals and alternative care: Noninstitutionalization as potential public policy for mental patients. Am Psychol

37:349-360, 1982.

318
McCrady, B.S., and Miller, W.R., eds. Research on Alcoholics

Anonymous: Opportunities and Alternatives. New Brunswick, NJ:

Rutgers Center of Alcohol Studies, in press.

McLellan, A.T.; Woody, G.E.; Luborsky, L.; and Goehl, L. Is the

counselor an “active ingredient” in substance abuse rehabilitation?

An examination of treatment success among four counselors.

J Nerv Ment Dis 176:423-430, 1988.

Miller, W.R. Behavioral treatment research advances: Barriers to

utilization. Adv Behav Res Ther 9:145-164, 1987.

Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhancing motivation

for change in problem drinking: A controlled comparison of two

therapist styles. J Consult Clin Psychol, in press.

Miller, W.R., and Brown, J.M. Self-regulation as a conceptual basis for

the prevention and treatment of addictive behaviours. In: Heather,

N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the

Addictive Behaviours. Sydney: Maxwell Macmillan Publishing

Australia, 1991.

Miller, W.R., and Hester, R.K. Treating the problem drinker: Modem

approaches. In: Miller, W.R., ed. The Addictive Behaviors:

Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity.

Elmsford, NY: Pergamon Press, 1980.

Miller, W.R., and Hester, R.K. Inpatient alcoholism treatment: Who

benefits? Am Psychol 41:794-805, 1986.

Miller, W.R.; Leckman, A.L.; Delaney, H.D.; and Tinkcom, M. Longterm follow-up of behavioral self-control training. J Stud Alcohol

53:249-261, 1992.

Miller, W.R., and Page, A. Warm turkey: Other routes to abstinence.

J Subst Abuse Treat 8:1227-232, 1991.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing

People To Change Addictive Behavior. New York: Guilford Press,

1991.

Miller, W.R.; Sovereign, R.G.; and Krege, B. Motivational

interviewing with problem drinkers: II. The Drinker’s Check-up as a

preventive intervention. Behav Psychother 16:251-268, 1988.

Miller, W.R.; Taylor, C.A.; and West, J.C. Focused versus broad

spectrum behavior therapy for problem drinkers. J Consult Clin

Psychol 48:590-601, 1980.

Moore, M.H., and Gerstein, D.R., eds. Alcohol and Public Policy:

Beyond the Shadow of Prohibition. Washington, DC: National

Academy Press, 1981.

319
Moyers, T.B. “Therapists’ Conceptualizations of Alcoholism:

Implications for Treatment Decisions.” Ph.D. diss., The University

of New Mexico, 1991.

National Academy of Sciences, Institute of Medicine. Prevention and

Treatment of Alcohol Problems: Research Opportunities.

Washington, DC: National Academy Press, 1989.

National Academy of Sciences, Institute of Medicine. Broadening the

Base of Treatment for Alcohol Problems. Washington, DC: National

Academy Press, 1990.

Rogers, R.W., and Mewborn, C.R. Fear appeals and attitude change:

Effects of a threat’s noxiousness, probability of occurrence, and the

efficacy of coping responses. J Pers Soc Psychol 34:54-61, 1976.

Sanchez-Craig, M., and Lei, H. Disadvantages of imposing the goal of

abstinence on problem drinkers: An empirical study. Br J Addict

81:505-512, 1986.

Saunders, B.; Wilkinson, C.; and Allsop, S. Motivational intervention

with heroin users attending a methadone clinic. In: Miller, W.R.,

and Rollnick, S. Motivational Interviewing: Preparing People To

Change Addictive Behavior. New York: Guilford Press, 1991.

pp. 279-292.

U.S. Congress, Office of Technology Assessment. The Effectiveness

and Costs of Alcoholism Treatment. Washington, DC: U.S. Govt.

Print. Off., 1983.

Vaillant, G.E. The Natural History of Alcoholism: Causes, Patterns,

and Paths to Recovery. Cambridge, MA: Harvard University Press,

1983.

Van Bilsen, H.P.J.G. Motivational interviewing: Perspectives from the

Netherlands, with particular emphasis on heroin-dependent clients.

In: Miller, W.R., and Rollnick, S. Motivational Interviewing:

Preparing People To Change Addictive Behavior. New York:

Guilford Press, 1991. pp. 214-224.

Wei, L.J. An application of an urn model to the design of sequential

controlled clinical trials. J Am Stat Assoc 73:559-563, 1978.

Wilkinson, D.A., and LeBreton, S. Early indications of treatment

outcome in multiple drug users. In: Miller, W.R., and Heather, N.,

eds. Treating Addictive Behaviors: Processes of Change. New York:

Plenum Press, 1986. pp. 239-261.

320
ACKNOWLEDGMENT

Preparation of this chapter was supported in part by grant number

K05-AA09051 from the National Institute on Alcohol Abuse and

Alcoholism.

AUTHOR

William R. Miller, Ph.D.

Professor of Psychology and Psychiatry

Department of Psychology

and

Director

Research Division

Center on Alcoholism, Substance Abuse, and Addictions (CASAA)

The University of New Mexico

Albuquerque, NM 87131-1161

321

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