Behavioral Therapies for Drug Abuse
Publication: American Journal of Psychiatry
Abstract
The past three decades have been marked by tremendous progress in behavioral therapies for drug abuse and dependence, as well as advances in the conceptualization of approaches to development of behavioral therapies. Cognitive behavior therapy, contingency management, couples and family therapy, and a variety of other types of behavioral treatment have been shown to be potent interventions for several forms of drug addiction, and scientific progress has also been greatly facilitated by the articulation of a systematic approach to the development, evaluation, and dissemination of behavioral therapies. The authors review recent progress in strategies for the development of behavioral therapies for drug and alcohol abuse and dependence and discuss the range of effective behavioral therapies that are currently available.
Before the advent of research on treatments derived from operant and classic behaviorism, there was little indication that any form of psychosocial treatment was effective for any type of mental disorder (1–3). Research on behavioral therapies flourished with the adoption of the technology model (4, 5), which sought to systematize these therapies and the experimental methods through which they could be evaluated to achieve a level of methodological rigor on a par with the standards for pharmacological research (6, 7). By the mid to late 1980s, there were a number of behavioral treatments that had been shown to be efficacious in the treatment of a variety of mental disorders, including depressive, panic, and obsessive-compulsive disorders. However, the methodological rigor and specificity that were characteristic of these studies were not yet apparent in drug abuse treatment studies, with a few exceptions (8). Although behavioral approaches were universally available in drug abuse treatment programs by the late 1980s (9), there was continued pessimism in the field regarding the efficacy of behavioral therapies for drug use disorders (10, 11).
In the early 1990s, studies in which behavioral therapies, therapist training, study populations, and objective outcome measures were carefully specified and in which participants were randomly assigned to experimental and control or comparison conditions began to appear more frequently in the drug abuse treatment literature. The technology model facilitated the identification of effective behavioral treatments for substance use disorders as it enhanced the internal validity and replicability of research on behavioral therapies. However, the technology model also had the unanticipated effect of restricting the development of novel therapies. The stringent methodological requirements associated with the technology model (e.g., requiring investigators to have fully developed treatment manuals, therapist training protocols, and fidelity rating procedures) limited the therapies eligible for efficacy evaluation to those already developed for drug abuse and to those which could easily be adapted from other areas (e.g., alcohol and depression treatments). This restriction created bottlenecks not only in the introduction of new treatments but also in output, as it limited research on the dissemination of behavioral treatments. That is, once efficacious treatments were identified, no articulated research strategy was available to determine how those treatments might best be transferred to and administered effectively in clinical settings.
The Stage Model and Reconceptualization of Behavioral Therapies Development
In 1992, the National Institute on Drug Abuse (NIDA) began to offer comprehensive support for a broader range of scientific activity in behavioral treatment development, spanning from origination and initial testing of novel behavioral therapies to their dissemination in community settings (12). Three stages were defined: 1) Stage I, which consists of pilot/feasibility testing for new and untested treatments, including preparation of treatment manuals, development of a training program, and development of adherence/competence measures for new and untested treatments, as well as translation of findings from basic science to clinical applications; 2) Stage II, which consists principally of efficacy testing to evaluate treatments that are fully developed and have shown promise or efficacy in earlier studies; and 3) Stage III, which is aimed principally at issues of transportability of approaches to community settings (13). By providing a scientific framework and support not only for efficacy testing at Stage II but for the development of novel approaches at Stage I and a wide range of dissemination/diffusion research at Stage III, this program expanded both the range and the rigor of clinical behavioral science.
Stage I is particularly innovative in that it permits greater creativity by allowing investigators to develop entirely new therapies or to adapt or improve existing therapies. Another critical component of Stage I research is the translation of ideas and concepts from basic or clinical science/neuroscience to treatment development. Hence, Stage I allows for cross-disciplinary research and also for the entry of higher-risk/higher-yield projects into the field. Additional goals of Stage I research include the identification of effective change principles and strategies through a focus on potential mechanisms of action, even at the earliest stages of treatment development.
Efficacy testing, including dose-response and dismantling studies, occurs in Stage II (principles and methods of which have been described in detail elsewhere [14]). Although research in Stage II can determine if a treatment can be effective, clarify how and why it works, and identify its essential components, it does not address whether a treatment will work in clinical practice. Hence, the goal of Stage III research is to produce all of the necessary knowledge to proceed to and conduct what is usually considered traditional “effectiveness” research, that is, an evaluation of whether an approach is effective when implemented by community-based clinicians in clinical settings. Stage III research addresses, at the therapy and therapist level, issues involved in ensuring that a treatment can work in a community setting. In Stage III research, investigators attempt to produce a treatment that shows efficacy in a community setting, as well as knowledge about how to implement the treatment effectively. Thus, in Stage III, research on questions of transportability, implementation, and acceptability (e.g., What is needed to train clinicians to learn to use an efficacious treatment?) are encouraged (15). For example, a Stage III study might include the development of therapist training procedures, followed by a randomized clinical trial to determine the effectiveness of those procedures. Alternatively, a Stage III study might simply determine the effectiveness of a therapy in a community setting or might compare, in a community setting, the effectiveness of a therapy in an individual format with the same therapy modified to a group format.
Thus, the stage model provides a conceptual framework and the necessary structure to produce treatments that are both efficacious and practical while at the same time fostering continued systematic improvements in those treatments through scientific advances.
Behavioral Therapies for Drug Abuse and Dependence
The following sections present a brief overview of progress made in the development of effective behavioral treatments for drug abuse and dependence, with a primary focus on the broader categories of treatment that have been found to be effective in Stage II randomized clinical trials (including contingency management, cognitive behavior approaches, motivational interviewing, and family/couples approaches) and on the major categories of drug dependence (opioids, cocaine, and marijuana dependence). Space limitations preclude a more comprehensive review of this burgeoning literature; hence, a number of important studies, populations (e.g., adolescents, smokers), and approaches (e.g., combined therapies, harm reduction) will not be highlighted here.
Contingency Management Therapies
Contingency management, in which patients receive incentives or rewards for meeting specific behavioral goals (e.g., verified abstinence), has particularly strong, consistent, and robust empirical support across a range of types of drug use. Contingency management approaches are based on principles of behavioral pharmacology and operant conditioning, in which behavior that is followed by positive consequences is more likely to be repeated. For example, allowing a patient the privilege of taking home methadone doses, contingent on the patient’s providing drug-free urine specimens, is associated with significant reductions in illicit drug use, and this strategy can be used address a number of other problems, such as benzodiazepine use, that are common in methadone maintenance programs (16, 17). This body of work also supports the view that positive incentives (e.g., rewards for desired behaviors) are more effective in producing improved substance use outcomes and in retaining patients in treatment than negative consequences (such as methadone dose reductions, restriction of clinic privileges, or termination of treatment) (18–21).
Despite consistent findings of the efficacy of contingent take-home privileges in methadone maintenance programs, contingency management procedures proved difficult to implement outside of methadone programs until the early 1990s, when Budney, Higgins, and their colleagues (22) demonstrated the efficacy of vouchers redeemable for goods and services, contingent on the patient’s providing cocaine-free urine specimens, in reducing targeted drug use and enhancing retention in treatment. A series of studies by Higgins and his colleagues indicated that the initiation of abstinence facilitated by contingent vouchers is associated with durable reductions in drug use (23, 24) and that the addition of the community reinforcement approach, which encompasses skills training, a job club, disulfiram therapy, and relationship counseling, can enhance treatment benefits (25).
Voucher-based incentives have been shown to be effective in improving retention and abstinence in outpatient opioid detoxification (26), in reducing smoking as well as illicit substance use among opioid addicts in a methadone maintenance program (27), in reducing the frequency of marijuana use (28), and in improving medication compliance among opioid-dependent individuals treated with naltrexone maintenance (29–31). Iguchi et al. (32) expanded voucher-based contingency management to outcomes other than drug-negative urine specimens, demonstrating that reinforcement of tasks outlined in an individualized, verifiable treatment plan was associated with greater reductions in illicit drug use than reinforcement of drug-free urine specimens. Voucher-based contingency management has also been shown to reduce cocaine (33, 34) and opioid (35) use in the context of methadone maintenance, thus extending the availability of contingency management procedures to methadone programs where the ability to offer take-home privileges is restricted. Silverman and colleagues (36, 37) demonstrated the efficacy of a therapeutic workplace for pregnant and postpartum drug-abusing women in a methadone maintenance program. Access to the therapeutic workplace, which provided job training and a salary, was linked to abstinence and was contingent on the participants’ producing drug-free urine specimens.
Despite these findings, questions have arisen regarding the applicability and sustainability of contingency management in clinical practice, especially in community-based treatment programs where the cost of the vouchers and the need for frequent urine monitoring can be prohibitive. These issues have been addressed in part by the work of Petry et al. (38), who developed a lower-cost contingency management procedure in which vouchers are not given but participants receive the opportunity to draw prizes of varying value, contingent on verifiable target behaviors such as provision of drug-free urine specimens. This approach has been effective in reducing drug use among methadone maintenance patients (39), as well as cocaine-dependent outpatients (40).
Although the consistent findings of effectiveness in contingency management interventions are compelling, some limitations have been noted. First, the effects tend to weaken after the contingencies are terminated. This problem might be addressed by evaluating combinations of contingency management with approaches that have more enduring effects, for example, by transferring rewards from monetary reinforcers to behaviors that are, in and of themselves, reinforcing or by exploring novel discontinuation strategies, such as lengthening periods between reinforcement or offering more intermittent reinforcements. Second, the cost of providing rewards and administering contingency management systems has been a barrier to the adoption of these approaches by the clinical community (41). Lower-cost contingency management approaches that use reinforcers without monetary value and that reinforce behaviors other than provision of drug-free urine samples are promising strategies, but there are no cost-effectiveness data that might persuade policy makers and third-party payers to support these approaches in clinical practice (15). Finally, because a substantial proportion of substance abusers does not respond to contingency management, there is a need to understand and address individual differences in response to these approaches.
Cognitive Behavior and Skills Training Therapies
Cognitive behavior approaches, such as relapse prevention, are grounded in social learning theories and principles of operant conditioning. The defining features of these approaches are 1) an emphasis on functional analysis of drug use, i.e., understanding drug use within the context of its antecedents and consequences, and 2) skills training, through which the individual learns to recognize the situations or states in which he or she is most vulnerable to drug use, avoid those high-risk situations whenever possible, and use a range of behavioral and cognitive strategies to cope effectively with those situations if they cannot be avoided (42, 43). Meta-analyses and extensive reviews of the literature have established that cognitive behavior approaches have strong empirical support for use in treatment of alcohol use disorders (44, 45) and several non-substance-related psychiatric disorders (46) and that these approaches have been demonstrated to be effective in drug-using populations as well (47). Several research groups have demonstrated the efficacy of cognitive behavior therapy in the treatment of cocaine-dependent outpatients, particularly depressed and more severely dependent cocaine users (48–54), and have shown that cognitive behavior therapy is compatible and possibly has additive effects when combined with pharmacotherapies such as disulfiram (55, 56).
Furthermore, cognitive behavior therapy is characterized by an emphasis on the development of skills that can be used initially to foster abstinence but can also be applied to a range of co-occurring problems. This feature may be a factor in emerging evidence for the long-term durability of the effects of cognitive behavior therapy. Several studies have demonstrated that cognitive behavior therapy’s effects are durable and that continuing improvement may occur even after the end of treatment (57, 58). These findings are consistent with evidence that cognitive behavior therapy may have enduring effects for other disorders, such as panic disorder and depression (59, 60). Delayed emergence of the effects of cognitive behavior therapy was highlighted in two studies that directly compared group cognitive behavior therapy and contingency management among cocaine-dependent patients in a methadone maintenance program (61, 62). Although end-of-treatment outcomes favored contingency management over cognitive behavior therapy, 1-year follow-up indicated significant continuing improvement for patients assigned to cognitive behavior therapy, in contrast to weakening effects for contingency management, which resulted in comparable, or slightly better, outcomes for cognitive behavior therapy at the end of follow-up. Extending the work on cognitive behavior therapy’s durability to panic disorder patients, two studies found that the addition of group cognitive behavior therapy to slow tapering of alprazolam or clonazepam for patients who were attempting to discontinue the benzodiazepine resulted in higher rates of successful discontinuation, compared with the use of slow tapering alone (63, 64).
Cognitive behavior interventions have also been evaluated as a component of multimodal treatment packages. For example, in a multisite study evaluating psychosocial treatments for methamphetamine-dependent individuals, the matrix model (a cognitive behavior approach that included group and individual treatment) was found to be more effective overall than standard treatment (65). Another multisite study involving 450 marijuana-dependent individuals demonstrated that a nine-session individual approach that integrated cognitive behavior therapy and motivational interviewing (66) was more effective than a two-session motivational interviewing approach, which was in turn more effective than a delayed-treatment control condition (67).
Despite the emerging empirical support for use of cognitive behavior therapy in drug-dependent populations, additional research is needed to address its limitations. Cognitive behavior therapy is a comparatively complex approach, and training clinicians to implement this approach effectively can be challenging. Strategies for addressing these issues include greater emphasis on understanding the mechanisms of action of cognitive behavior therapy so that ineffective components can be removed and treatment delivery can be simplified and shortened and perhaps even accomplished by computer or other automated means. Strategies for enhancing acceptance and effective implementation of cognitive behavior therapy by the clinical community are also needed.
Motivational Interviewing
Motivational interviewing is based on principles of motivational psychology and is intended to enhance the individual’s intrinsic motivation for change (66). Motivational interviewing approaches have strong empirical support for use in treating alcohol users, with several studies showing significant and durable effects (68–70). More recently, motivational interviewing has been evaluated as treatment for drug users. For example, marijuana-dependent adults who received motivational interviewing had significant reductions in marijuana use, compared to a delayed-treatment control group (71). A combination of motivational interviewing with behavioral skills training was found to reduce HIV risk behaviors among low-income urban women (72, 73).
However, several clinical trials have not supported the efficacy of motivational interviewing as an engagement strategy for general populations of substance users. These trials include studies of the effects of motivational interviewing on drug use outcomes among inpatients and outpatients entering community-based treatment (74), on attrition among individuals on a waiting list for publicly funded drug treatment (75), on treatment entry among intravenous drug users (76), and on engagement in a specialized substance misuse program among psychiatric inpatients (77). The mixed results of these studies and of smaller pilot studies in other populations suggest that single-session motivational interviewing may not greatly enhance engagement or outcome in general populations of illicit drug users. There is stronger support for motivational interviewing combined with other evidence-based therapies for drug abusers, although the combination of treatments precludes attribution of benefit to any single component. More work is needed to identify the populations that best respond to motivational interviewing and to determine how motivational interviewing enhances change among users of illicit drugs.
Couples and Family Treatments
The defining feature of couples and family treatments is that they treat drug-using individuals in the context of family and social systems in which substance use may develop or be maintained. The engagement of the individual’s social networks in treatment can be a powerful predictor of change, and thus the inclusion of family members in treatment may be helpful in reducing attrition (particularly among adolescents) and addressing multiple problem areas (78, 79). Meta-analyses have strongly supported the efficacy of these approaches for both adult (80) and adolescent substance users (81–83). It is important to note that family-based approaches are quite diverse, and it is unlikely that all are equally effective. Moreover, many family-based approaches combine a variety of techniques, including family and individual therapies, skills training, and communication training (84).
Behavioral couples therapy and behavioral family counseling combine abstinence contracts and behavioral principles to reinforce abstinence from drugs; these approaches require the participation of a non-substance-abusing spouse or cohabitating partner (85). Among men entering methadone maintenance treatment, behavioral couples therapy was more effective than equally intensive individual services in reducing the frequency of cocaine- or opioid-positive urine tests during treatment; behavioral couples therapy was also associated with better ratings of happiness in the relationship and fewer family and social problems (86). A study evaluating the addition of behavioral family counseling to individual treatment for men entering naltrexone treatment found that behavioral family counseling was associated with better retention and naltrexone compliance, as well as better substance use outcomes during treatment and through a 1-year follow-up (87). Moreover, even though the children of participants were not directly targeted by the intervention, the children of the adults who received behavioral couples therapy had meaningful improvements in psychosocial functioning, relative to the children of parents assigned to the control condition (88). These findings highlight the possibility that effective treatment of substance-using parents may ameliorate and conceivably prevent problems in their children.
Several family therapies have been demonstrated to be effective among drug-using adolescents. Azrin’s family behavior therapy, which combines behavioral contracting with contingency management, was found to be more effective than supportive counseling in a series of comparisons involving adolescents with substance use disorders with and without conduct disorder (89). Multisystemic therapy is a manual-based approach that addresses multiple determinants of drug use and antisocial behavior and is intended to promote more family involvement by engaging family members as collaborators in treatment, emphasizing the strengths of youths and their families, and addressing a broad and comprehensive array of barriers to attaining treatment goals (90). Henggeler and colleagues (78, 91–94) have demonstrated the efficacy and durability of multisystemic therapy in retaining patients and broadly improving outcomes among substance-using juvenile offenders, compared with similar juvenile offenders who received the usual community treatment services. Brief strategic family therapy (95) has also received a substantial level of empirical support. In contrast to the other family therapies for adolescents reviewed here, brief strategic family therapy is somewhat less intensive, as it targets fewer systems and can be delivered through once-a-week office visits. Brief strategic family therapy has been associated with improved retention (96–98), as well as significant reductions in the frequency of externalizing behaviors (aggression, delinquency) (99). Multidimensional family therapy is a multicomponent, staged family therapy that incorporates both individual and family formats and targets the substance-abusing youth, the family members, and their interactions (81). Liddle et al. (79) demonstrated that multidimensional family therapy was more effective than group therapy or multifamily education among substance-abusing adolescents who were referred to treatment by the criminal justice system or by schools.
The body of work on family and couples approaches is marked by the consistency of positive findings regarding the efficacy of these approaches. However, because most of these approaches include multiple components, it has not yet been possible to isolate the components that are associated with the treatment effects or to determine if some components can be eliminated without weakening outcomes overall. The efficacy of several of these approaches has not yet been replicated by other investigators, and whether there are meaningful differences in outcome across the various family approaches is not yet clear. Finally, these approaches have been evaluated in comparatively small groups of individuals who have appropriate family members (i.e., family members who are not abusing substances) who are willing to participate in treatment. Evaluation of the effectiveness of these approaches in the general population is needed.
Drug Counseling
Another major development of the past 10 years has been efforts to rigorously evaluate approaches similar to those widely used in clinical practice. For example, researchers have specified the elements of drug counseling approaches in detailed manuals for therapists and have evaluated these approaches in clinical trials. A multisite randomized clinical trial of psychotherapeutic treatments for cocaine dependence (100) provided evidence of the effectiveness of a manual-guided individual drug counseling approach that combined drug counseling and relapse-prevention techniques (101). Data from this study also indicated that the reductions in cocaine use were associated with sharp decreases in the frequency of HIV risk behaviors (102), underscoring the view that effective drug abuse treatment constitutes effective HIV prevention (103).
HIV Risk Reduction
Behavioral therapies have been demonstrated to be effective in reducing HIV risk behaviors and promoting health in intravenous drug users enrolled in methadone maintenance programs. Two randomized clinical trials found that the Holistic Harm Reduction Program, developed to reduce HIV risk behaviors, illicit drug use, and transmission of infectious diseases (e.g., HIV, hepatitis B and C), reduced illicit drug use and risky sexual behavior and, among HIV-positive participants, improved adherence to antiretroviral treatment (104, 105). Although these findings are promising, this approach has been evaluated in a fairly narrow range of populations and requires replication in other settings and other groups of drug users.
Future Directions
The findings of research on behavioral treatments have been positive, but there is still a great deal more to be done. Even the most powerful behavioral therapies are not universally effective, nor do all individuals who benefit from these treatments improve as quickly or as completely as desired. There are many ways to improve behavioral therapies at all three stages of treatment development.
Stage I research provides the opportunity for clinical creativity and innovation in clinical behavioral science. Research at this stage has the potential for a high yield from evaluation of clinical strategies that have not yet been subject to empirical evaluation, from the adaptation of effective treatments used for other disorders, and from translation of concepts from basic science to clinical applications. Basic neuroscience and basic research on behavioral, cognitive, affective, and social factors offer rich and relatively untapped sources of information on behavior and behavior change. With the development of new technologies of brain imaging, behavioral treatments based on a new understanding of the brain could be on the horizon.
At Stage II, renewed emphasis is needed on improving understanding of the mechanisms of action in treatments with established efficacy, not only to enhance their effectiveness but also to increase the efficiency of treatment delivery. Currently underutilized strategies for investigating mechanisms of action include 1) evaluating novel combinations of behavioral therapies or psychotherapy/pharmacotherapy combinations, both to enhance treatment efficacy and to offset weaknesses of a single approach; 2) investigating individual differences in treatment response and in treatment moderators by using novel methods that may in the near future include subtyping and predictor analyses involving neuroimaging, stress-response paradigms, and genetics; and 3) developing strategies to investigate sequenced interventions, in which treatments or treatment components are delivered on the basis of the individual drug user’s characteristics, including previous treatment response, neurocognitive functioning, and family history. Finally, greater emphasis is needed on enhancing adherence and response to existing behavioral and pharmacological approaches.
At Stage III, promising strategies include evaluation of the means by which efficacious treatments can be reduced in duration, complexity, and cost. Projects to make behavioral treatments more “community friendly” are needed for treatments that show efficacy but are not deemed feasible for use by treatment providers or the treatment system. For example, individual treatments could be transformed into group-based approaches that would have wider acceptability in clinical practice. Simplified training procedures should be developed for treatments that are difficult for practitioners to learn. New information technologies should be considered, both as a means to improve treatment efficacy and as a way to make treatments more readily available and easier for patients and practitioners to use.
In summary, the level of progress in the behavioral treatment of drug abuse in recent years has exceeded what many researchers and practitioners had believed possible. Efficacious behavioral treatments exist, and conditions for which efficacious medications exist can be treated with combinations of behavioral and pharmacological treatments that have even greater potency than either type of treatment alone. More work can be done to improve effect sizes in research on behavioral treatments and to develop strategies to help drug users who do not respond to existing treatments. Work on the mechanisms of action of behavioral treatments, in addition to translational efforts to link basic science and neuroscience with treatment development, promises to yield new insights that will help to make drug abuse not only treatable but treated.
Footnote
Received Nov. 30, 2004; revision received Jan. 28, 2005; accepted Feb. 4, 2005. From the Department of Psychiatry, Yale University School of Medicine; and the National Institute on Drug Abuse, Bethesda, Md. Address correspondence and reprint requests to Dr. Carroll, Department of Psychiatry, Yale University School of Medicine, 950 Campbell Ave. (151D), West Haven, CT 06519; [email protected] (e-mail). Supported by National Institute on Drug Abuse grants R01 DA-10679, K05 DA-00457, and P50 DA-09241.
References
1.
Sargent S: The treatment of depressive states. Int J Neurol 1967; 6:53–64
2.
Agras WS, Chapin HN, Oliveau DC: The natural history of phobia. Arch Gen Psychiatry 1972; 26:315–317
3.
Marks IM: New approaches to the treatment of obsessive-compulsive disorders. J Nerv Ment Dis 1973; 156:420–426
4.
Waskow IE: Specification of the technique variable in the NIMH Treatment of Depression Collaborative Research Program, in Psychotherapy Research: Where Are We and Where Should We Go? Edited by Williams JBW, Spitzer RL. New York, Guilford, 1984, pp 150–159
5.
Docherty JP: Implications of the technological model of psychotherapy. Ibid, pp 139–149
6.
Elkin I, Pilkonis PA, Docherty JP, Sotsky SM: Conceptual and methodologic issues in comparative studies of psychotherapy and pharmacotherapy, I: active ingredients and mechanisms of change. Am J Psychiatry 1988; 145:909–917
7.
Elkin I, Pilkonis PA, Docherty JP, Sotsky SM: Conceptual and methodological issues in comparative studies of psychotherapy and pharmacotherapy, II: nature and timing of treatment effects. Am J Psychiatry 1988; 145:1070–1076
8.
Woody GE, Luborsky L, McLellan AT, O’Brien CP, Beck AT, Blaine JD, Herman L, Hole A: Psychotherapy for opiate addicts: does it help? Arch Gen Psychiatry 1983; 40:639–645
9.
Onken LS, Blaine JD: Psychotherapy and counseling research in drug abuse treatment: questions, problems, and solutions. NIDA Research Monogr 1990; 104:1–8
10.
Kang SY, Kleinman PH, Woody GE, Millman RB, Todd TC, Kemp J, Lipton DS: Outcomes for cocaine abusers after once-a-week psychosocial therapy. Am J Psychiatry 1991; 148:630–635
11.
Kleber HD, Gawin FH: Cocaine abuse: a review of current and experimental treatments, in Cocaine: Pharmacology, Effects and Treatment of Abuse. DHHS Publication (ADM) 84–1326. Edited by Grabowski J. Rockville, Md, National Institute on Drug Abuse, 1984, pp 111–129
12.
Onken LS, Blaine JD, Battjes R: Behavioral therapy research: a conceptualization of a process, in Innovative Approaches for Difficult-to-Treat Populations. Edited by Henggeler SW, Santos AB. Washington, DC, American Psychiatric Press, 1996, pp 477–485
13.
Rounsaville BJ, Carroll KM, Onken LS: A stage model of behavioral therapies research: getting started and moving on from Stage I. Clin Psychol Sci Pract 2001; 8:133–142
14.
Kazdin AE: Comparative outcome studies in psychotherapy: methodological issues and strategies. J Consult Clin Psychol 1986; 54:95–105
15.
Carroll KM, Rounsaville BJ: Bridging the gap between research and practice in substance abuse treatment: a hybrid model linking efficacy and effectiveness research. Psychiatr Serv 2003; 54:333–339
16.
Stitzer ML, Bickel WK, Bigelow GE, Liebson IA: Effect of methadone dose contingencies on urinalysis test results of polydrug abusing methadone maintenance patients. Drug Alcohol Depend 1986; 18:341–348
17.
Stitzer ML, Iguchi MY, Felch LJ: Contingent take-home incentives: effects on drug use of methadone maintenance patients. J Consult Clin Psychol 1992; 60:927–934
18.
Dolan MP, Black JL, Penk WE, Rabinowitz R, DeFord HA: Contracting for treatment termination to reduce illicit drug use among methadone maintenance treatment failures. J Consult Clin Psychol 1985; 53:549–551
19.
Kidorf M, Stitzer ML: Contingent use of take-homes and split-dosing to reduce illicit drug use of methadone patients. Behav Ther 1996; 27:41–51
20.
Iguchi MY, Stitzer ML, Bigelow GE, Liebson IA: Contingency management in methadone maintenance: effects of reinforcing and aversive consequences on illicit polydrug use. Drug Alcohol Depend 1988; 22:1–7
21.
Stitzer ML, Iguchi MY, Kidorf M, Bigelow GE: Contingency management in methadone treatment: the case for positive incentives, in Behavioral Treatments for Drug Abuse and Dependence. Edited by Onken LS, Blaine JD, Boren JJ. Rockville, Md, National Institute on Drug Abuse, 1993, pp 19–36
22.
Budney AJ, Higgins ST, Mercer DE, Carpenter G: A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction. NIH Publication 98–4309. Rockville, Md, National Institute on Drug Abuse, 1998
23.
Higgins ST, Wong CJ, Badger GJ, Ogden DE, Dantona RL: Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol 2000; 68:64–72
24.
Higgins ST, Badger GJ, Budney AJ: Initial abstinence and success in achieving longer term cocaine abstinence. Exp Clin Psychopharmacol 2000; 8:377–386
25.
Higgins ST, Sigmon SC, Wong CJ, Heil SH, Badger GJ, Donham R, Dantona RL, Anthony S: Community reinforcement therapy for cocaine-dependent outpatients. Arch Gen Psychiatry 2003; 60:1043–1052
26.
Bickel WK, Amass L, Higgins ST, Badger GJ, Esch RA: Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 1997; 65:803–810
27.
Shoptaw S, Rotheram-Fuller E, Yang X, Frosch D, Nahom D, Jarvik ME, Rawson RA, Ling W: Smoking cessation in methadone maintenance. Addiction 2002; 97:1317–1328
28.
Budney AJ, Higgins ST, Radonovich KJ, Novy PL: Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol 2000; 68:1051–1061
29.
Preston KL, Silverman K, Umbricht A, DeJesus A, Montoya ID, Schuster CR: Improvement in naltrexone treatment compliance with contingency management. Drug Alcohol Depend 1999; 54:127–135
30.
Carroll KM, Ball SA, Nich C, O’Connor PG, Eagan D, Frankforter TL, Triffleman EG, Shi J, Rounsaville BJ: Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: efficacy of contingency management and significant other involvement. Arch Gen Psychiatry 2001; 58:755–761
31.
Carroll KM, Sinha R, Nich C, Babuscio T, Rounsaville BJ: Contingency management to enhance naltrexone treatment of opioid dependence: a randomized clinical trial of reinforcement magnitude. Exp Clin Psychopharmacol 2002; 10:54–63
32.
Iguchi MY, Belding MA, Morral AR, Lamb RJ, Husband SD: Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use. J Consult Clin Psychol 1997; 65:421–428
33.
Silverman K, Higgins ST, Brooner RK, Montoya ID, Cone EJ, Schuster CR, Preston KL: Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Arch Gen Psychiatry 1996; 53:409–415
34.
Silverman K, Wong CJ, Umbricht-Schneiter A, Montoya ID, Schuster CR, Preston KL: Broad beneficial effects of cocaine abstinence reinforcement among methadone patients. J Consult Clin Psychol 1998; 66:811–824
35.
Silverman K, Wong CJ, Higgins ST, Brooner RK, Montoya ID, Contoreggi C, Umbricht-Schneiter A, Schuster CR, Preston KL: Increasing opiate abstinence through voucher-based reinforcement therapy. Drug Alcohol Depend 1996; 41:157–165
36.
Silverman K, Svikis DS, Robles E, Stitzer ML, Bigelow GE: A reinforcement-based therapeutic workplace for the treatment of drug abuse: six-month abstinence outcomes. Exp Clin Psychopharmacol 2001; 9:14–23
37.
Silverman K, Svikis DS, Wong CJ, Hampton J, Stitzer ML, Bigelow GE: A reinforcement-based therapeutic workplace for the treatment of drug abuse: three-year abstinence outcomes. Exp Clin Psychopharmacol 2002; 10:228–240
38.
Petry NM, Martin B, Cooney JL, Kranzler HR: Give them prizes and they will come: contingency management treatment of alcohol dependence. J Consult Clin Psychol 2000; 68:250–257
39.
Petry NM, Martin B: Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. J Consult Clin Psychol 2002; 70:398–405
40.
Petry NM, Tedford J, Austin M, Nich C, Carroll KM, Rounsaville BJ: Prize reinforcement contingency management for treating cocaine abusers: how low can we go, and with whom? Addiction 2004; 99:349–360
41.
Crowley TJ: Research on contingency management treatment of drug dependence: clinical implications and future directions, in Motivating Behavior Change Among Illicit Drug Abusers. Edited by Higgins ST, Silverman K. Washington, DC, American Psychological Association, 1999, pp 345–370
42.
Carroll KM: A Cognitive-Behavioral Approach: Treating Cocaine Addiction. NIH Publication 98–4308. Rockville, Md, National Institute on Drug Abuse, 1998
43.
Marlatt GA, Gordon JR: Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, Guilford, 1985
44.
Miller WR, Wilbourne PL: Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97:265–277
45.
Miller WR, Brown JM, Simpson TL, Handmaker NS, Bien TH, Luckie LF, Montgomery HA, Hester RK, Tonigan JS: What works? a methodological analysis of the alcohol treatment literature, in Handbook of Alcoholism Treatment Approaches: Effective Alternatives. Edited by Hester RK, Miller WR. Boston, Allyn & Bacon, 1995, pp 12–44
46.
DeRubeis RJ, Crits-Christoph P: Empirically supported individual and group psychological treatments for adult mental disorders. J Consult Clin Psychol 1998; 66:37–52
47.
Irvin JE, Bowers CA, Dunn ME, Wong MC: Efficacy of relapse prevention: a meta-analytic review. J Consult Clin Psychol 1999; 67:563–570
48.
Maude-Griffin PM, Hohenstein JM, Humfleet GL, Reilly PM, Tusel DJ, Hall SM: Superior efficacy of cognitive-behavioral therapy for crack cocaine abusers: main and matching effects. J Consult Clin Psychol 1998; 66:832–837
49.
Rohsenow DJ, Monti PM, Martin RA, Michalec E, Abrams DB: Brief coping skills treatment for cocaine abuse: 12-month substance use outcomes. J Consult Clin Psychol 2000; 68:515–520
50.
Monti PM, Rohsenow DJ, Michalec E, Martin RA, Abrams DB: Brief coping skills treatment for cocaine abuse: substance abuse outcomes at three months. Addiction 1997; 92:1717–1728
51.
McKay JR, Alterman AI, Cacciola JS, Rutherford MJ, O’Brien CP, Koppenhaver J: Group counseling versus individualized relapse prevention aftercare following intensive outpatient treatment for cocaine dependence. J Consult Clin Psychol 1997; 65:778–788
52.
Carroll KM, Rounsaville BJ, Gordon LT, Nich C, Jatlow PM, Bisighini RM, Gawin FH: Psychotherapy and pharmacotherapy for ambulatory cocaine abusers. Arch Gen Psychiatry 1994; 51:177–197
53.
Carroll KM, Rounsaville BJ, Gawin FH: A comparative trial of psychotherapies for ambulatory cocaine abusers: relapse prevention and interpersonal psychotherapy. Am J Drug Alcohol Abuse 1991; 17:229–247
54.
Rosenblum A, Magura S, Palij M, Foote J, Handlesman L, Stimmel B: Enhanced treatment outcomes for cocaine-using methadone patients. Drug Alcohol Depend 1999; 54:207–218
55.
Carroll KM, Nich C, Ball SA, McCance-Katz E, Rounsaville BJ: Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram. Addiction 1998; 93:713–728
56.
Carroll KM, Fenton LR, Ball SA, Nich C, Frankforter TL, Shi J, Rounsaville BJ: Efficacy of disulfiram and cognitive-behavioral therapy in cocaine-dependent outpatients: a randomized placebo controlled trial. Arch Gen Psychiatry 2004; 64:264–272
57.
Carroll KM, Rounsaville BJ, Nich C, Gordon LT, Wirtz PW, Gawin FH: One year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects. Arch Gen Psychiatry 1994; 51:989–997
58.
Carroll KM, Nich C, Ball SA, McCance-Katz EF, Frankforter TF, Rounsaville BJ: One-year follow-up of disulfiram and psychotherapy for cocaine-alcohol abusers: sustained effects of treatment. Addiction 2000; 95:1335–1349
59.
Barlow DH: Cognitive behavioral therapy for panic disorder: current status. J Clin Psychiatry 1997; 58(suppl 2):32–36
60.
Hollon SD, Shelton RC, Davis DD: Cognitive therapy for depression: conceptual issues and clinical efficacy. J Consult Clin Psychol 1993; 61:270–275
61.
Rawson RA, Huber A, McCann MJ, Shoptaw S, Farabee D, Reiber C, Ling W: A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance for cocaine dependence. Arch Gen Psychiatry 2002; 59:817–824
62.
Epstein DE, Hawkins WE, Covi L, Umbricht A, Preston KL: Cognitive behavioral therapy plus contingency management for cocaine use: findings during treatment and across 12-month follow-up. Psychol Addict Behav 2003; 17:73–82
63.
Otto MW, Pollack MH, Sachs GS, Reiter SR, Maltzer-Brody S, Rosenbaum JF: Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J Psychiatry 1993; 150:1485–1490
64.
Spiegel DA, Bruce TJ, Gregg SF, Nuzzarello A: Does cognitive behavior therapy assist slow-taper alprazolam discontinuation in panic disorder? Am J Psychiatry 1994; 151:876–881
65.
Rawson RA, Marinelli Casey PJ, Anglin MD, Dickow A, Frazier Y, Gallagher C, Galloway GP, Herrell J, Huber A, McCann MJ, Obert J, Pennell S, Reiber C, Vandersloot D, Zweben J (Methamphetamine Treatment Project Corporate Authors): A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction 2004; 99:708–717
66.
Miller WR, Rollnick S: Motivational Interviewing: Preparing People for Change, 2nd ed. New York, Guilford, 2002
67.
MTP Research Group: Brief treatments for cannabis dependence: findings from a randomized multisite trial. J Consult Clin Psychol 2004; 72:455–466
68.
Dunn C, Deroo I, Rivara FP: The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001; 96:1725–1742
69.
Burke BL, Arkowitz H, Menchola M: The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003; 71:843–861
70.
Project MATCH Research Group: Matching alcohol treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol 1997; 58:7–29
71.
Stephens R, Roffman RA, Curtin L: Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol 2000; 68:898–908
72.
Carey MP, Maisto SA, Kalichman SC, Forsythe AD, Wright EM, Johnson BT: Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women. J Consult Clin Psychol 1997; 65:531–541
73.
Carey MP, Braaten LS, Maisto SA, Gleason JR, Forsythe AD, Durant LE, Jaworski BC: Using information, motivational enhancement, and skills training to reduce the risk of HIV infection for low-income urban women: a second randomized clinical trial. Health Psychol 2000; 19:3–11
74.
Miller WR, Yahne CE, Tonigan JS: Motivational interviewing in drug abuse services: a randomized trial. J Consult Clin Psychol 2003; 71:754–763
75.
Donovan DM, Rosengren DB, Downey L, Cox GC, Sloan KL: Attrition prevention with individuals awaiting publicly funded drug treatment. Addiction 2001; 96:1149–1160
76.
Booth RE, Kwiatkowski C, Iguchi MY, Pinto F, John D: Facilitating treatment entry among out-of-treatment injection drug users. Public Health Rep 1998; 113(suppl 1):116–128
77.
Baker A, Lewin T, Reichler H, Clancy R, Carr V, Garret R, Sly K, Devir H, Terry M: Motivational interviewing among psychiatric inpatients with substance use disorders. Acta Psychiatr Scand 2002; 106:233–240
78.
Henggeler SW, Pickrel SG, Brondino MJ, Crouch JL: Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home-based multisystemic therapy. Am J Psychiatry 1996; 153:427–428
79.
Liddle HA, Dakof GA, Parker K, Diamond GS, Barrett K, Tejeda M: Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial. Am J Drug Alcohol Abuse 2001; 27:651–688
80.
Stanton MD, Shadish WR: Outcome, attrition, and family-couples treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies. Psychol Bull 1997; 122:170–191
81.
Liddle HA, Dakof G: Efficacy of family therapy for drug abuse: promising but not definitive. J Marital Fam Ther 1995; 21:511–543
82.
Waldron HB: Adolescent substance abuse and family therapy outcome: a review of randomized trials. Adv Clin Child Psychol 1997; 19:199–234
83.
Deas D, Thomas SE: An overview of controlled studies of adolescent substance abuse treatment. Am J Addict 2001; 10:178–189
84.
Waldron HB, Slesnick N, Brody JL, Turner CW, Peterson TR: Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. J Consult Clin Psychol 2001; 69:802–813
85.
Fals-Stewart W, O’Farrell TJ, Birchler GR: Behavioral couples therapy for male substance-abusing patients: a cost outcomes analysis. J Consult Clin Psychol 1997; 65:789–802
86.
Fals-Stewart W, O’Farrell TJ, Birchler GR: Behavioral couples therapy for male methadone patients: effects on drug-using behavior and relationship adjustment. Behav Ther 2001; 32:391–411
87.
Fals-Stewart W, O’Farrell TJ: Behavioral family counseling and naltrexone for male opioid-dependent patients. J Consult Clin Psychol 2003; 71:432–442
88.
Kelley ML, Fals-Stewart W: Couples- versus individual-based therapy for alcohol and drug abuse: effects on children’s psychosocial functioning. J Consult Clin Psychol 2002; 70:417–427
89.
Azrin NH, Donohue B, Besalel VA, Kogan ES, Acierno R: Youth drug abuse treatment: a controlled outcome study. J Child Adolesc Subst Abuse 1994; 3:1–16
90.
Henggeler SW, Borduin CM: Family Therapy and Beyond: A Multisystemic Approach to Treating the Behavior Problems of Children and Adolescents. Pacific Grove, Calif, Brooks/Cole, 1990
91.
Henggeler SW, Melton GB, Smith LA: Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders. J Consult Clin Psychol 1992; 60:953–961
92.
Borduin CM, Mann BJ, Cone LT, Henggeler SW, Fucci BR, Blaske DM, Williams RA: Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence. J Consult Clin Psychol 1995; 63:569–578
93.
Huey SJ, Henggeler SW, Brondino MJ, Pickrel SG: Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning. J Consult Clin Psychol 2000; 68:451–467
94.
Henggeler SW, Clingempeel WG, Brondino MJ, Pickrel SG: Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. J Am Acad Child Adolesc Psychiatry 2002; 41:868–874
95.
Szapocznik J, Hervis O, Schwartz S: Brief Strategic Family Therapy for Adolescent Drug Abuse. NIH Publication 03–4751. Bethesda, Md, National Institute on Drug Abuse, 2003
96.
Szapocznik J, Perez-Vidal A, Brickman AL, Foote FH, Santisteban DA, Hervis O, Kurtines WM: Engaging adolescent drug abusers and their families in treatment: a strategic structural systems approach. J Consult Clin Psychol 1988; 56:552–557
97.
Santisteban DA, Coatsworth JD, Perez-Vidal A, Mitrani V, Jean-Gilles M, Szapocznik J: Engaging behavior problem/drug abusing youth and their families in treatment: a replication and further exploration of the factors that contribute to differential effectiveness. J Fam Psychol 1996; 10:35–44
98.
Coatsworth JD, Santisteban DA, McBride CK, Szapocznik J: Brief strategic family therapy versus community control: engagement, retention, and an exploration of the moderating role of adolescent severity. Fam Process 2001; 40:313–332
99.
Szapocznik J, Kurtines WM, Foote FH, Perez-Vidal A, Hervis O: Conjoint versus one-person family therapy: some evidence for the effectiveness of conducting family therapy through one person. J Consult Clin Psychol 1986; 54:395–397
100.
Crits-Christoph P, Siqueland L, Blaine JD, Frank A, Luborsky L, Onken LS, Muenz L, Thase ME, Weiss RD, Gastfriend DR, Woody G, Barber JP, Butler S, Dale D, Salloum I, Bishop S, Najavits L, Lis J: Psychosocial treatments for cocaine dependence: results of the National Institute on Drug Abuse Collaborative Cocaine Study. Arch Gen Psychiatry 1999; 56:495–502
101.
Mercer DE, Woody GE: An Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model. NIH Publication 99–4380. Rockville, Md, National Institute on Drug Abuse, 1999
102.
Woody GE, Gallop R, Luborsky L, Blaine JD, Frank A, Salloum IM, Gastfriend DR, Crits-Christoph P (Cocaine Psychotherapy Study Group): HIV risk reduction in the National Institute on Drug Abuse Cocaine Collaborative Treatment Study. J Acquir Immune Defic Syndr 2003; 33:82–87
103.
Sorensen JL, Copeland AL: Drug abuse treatment as an HIV prevention strategy: a review. Drug Alcohol Depend 2000; 59:17–31
104.
Margolin A, Avants SK, Warburton LA, Hawkins KA, Shi J: A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users. Health Psychol 2003; 22:223–228
105.
Avants SK, Margolin A, Usubiaga MH, Doebrick C: Targeting HIV-related outcomes with intravenous drug users maintained on methadone: a randomized clinical trial of harm reduction group therapy. J Subst Abuse Treat 2004; 26:67–78
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