Community Reinforcement Approach and Contingency Management Therapies

Introduction

This chapter describes the rationale behind and evidence in support of the efficacy of two reinforcement-based therapies: community reinforcement approach therapy and contingency management. The first section of the chapter reviews the evidence for the community reinforcement approach and recent studies extending the approach to adolescents with substance use disorders. The second section of this chapter details the theoretical basis and evidence of efficacy for contingency management interventions. The chapter concludes by discussing issues related to the cost-effectiveness of these interventions and their adoption in practice settings.

Community Reinforcement Approach Therapy

Community reinforcement approach therapy was first developed more than 40 years ago by Hunt and Azrin. They described the community reinforcement approach as a comprehensive biopsychosocial treatment for alcohol dependence. It is based on the theoretical view that individuals use substances for their positive, reinforcing effects and that the relative lack of alternative, nondrug reinforcers maintains dependence. The development of alternative reinforcing activities that are incompatible with drug use is central to the community reinforcement approach.

The community reinforcement approach begins with a detailed functional analysis concerning the triggers and consequences of drug use behaviors. An example of a functional analysis is presented in Table 41.1 . The treatment package itself includes a number of aspects: sobriety sampling, monitored disulfiram consumption (when appropriate), behavioral skills training, social and recreational counseling, behavioral marital therapy, problem solving, and drink refusal skills. Thus some of the components of the community reinforcement approach are similar to those of cognitive behavioral therapy (see Chapter 40 ).

The difference between the two types of therapies is that the community reinforcement approach is more directive, community based, and behavioral than cognitive behavioral therapy. In the community reinforcement approach, the therapist places a great deal of emphasis on changing environmental contingencies in the client’s life. Employment, recreation, and family systems are all addressed to promote a lifestyle that is more reinforcing than substance use. Rather than being entirely office-based, the community reinforcement approach is typically performed, at least in part, in the community. If clients do not attend treatment or do not follow through with an employment or recreational goal, the therapist may go to their homes, take them to job interviews, or help them try a new recreational activity. The purpose of expanding the treatment beyond the office setting is to increase the positive reinforcing effects of non–substance-using activities by direct exposure.

Initial reports of the efficacy of the community reinforcement approach for the treatment of alcohol dependence were promising. Hunt and Azrin and Azrin described two early studies in which 16 and 18 alcohol-dependent individuals, respectively, were randomized to usual psychosocial therapy plus disulfiram or to the community reinforcement approach plus disulfiram. In both studies, the community reinforcement approach–treated individuals spent significantly fewer days drinking than did individuals receiving usual care. The latter study had a long-term follow-up, which found that 90% of clients who had received the community reinforcement approach remained abstinent up to 2 years later.

Additional studies in alcohol-dependent individuals have found the community reinforcement approach to be of therapeutic benefit. For example, Azrin and colleagues noted a therapeutic benefit of the community reinforcement approach, and Smith et al. also reported that this approach led to greater abstinence during treatment than did usual care plus disulfiram treatment. Miller et al. examined the various components of the community reinforcement approach and likewise found that this approach improved the treatment outcomes of individuals who received concomitant disulfiram treatment.

Several independent reviews and meta-analyses have concluded that the community reinforcement approach is an important, established, and effective treatment for alcohol use disorders. Furthermore, in a systematic review of the community reinforcement approach’s effectiveness, Roozen et al. concluded that the community reinforcement approach, alone or with disulfiram, is efficacious for the treatment of alcohol dependence. The use of the community reinforcement approach in the treatment of other substance use disorders has not been examined as extensively.

Much recent research focuses on an adaptation of the community reinforcement approach for adolescents (A-CRA) or combined with family training (CRAFT) to involve significant others in the treatment process and teach them how to maintain alternative reinforcements to substance use. Randomized controlled trials of A-CRA demonstrate its efficacy in reducing cannabis use in adolescents. So far, most clinics implementing A-CRA have done so in the context of grant-funded research studies, and studies are underway to identify factors that facilitate sustained use of A-CRA after study funding ends. A recent review of four studies suggests that CRAFT was associated with increased patient engagement and reduced depression symptoms relative to comparison treatments.

Many studies have examined the community reinforcement approach in combination with another behavioral therapy, contingency management.

Contingency Management Interventions

Similar to the community reinforcement approach, contingency management is based on the principles of behavioral therapy. The primary difference between the two interventions is that contingency management provides tangible reinforcers for achieving target behaviors to increase the likelihood of those behaviors reoccurring, whereas the community reinforcement approach exposes clients to reinforcing activities and experiences. Typically, contingency management interventions identify an appropriate target behavior (e.g., abstinence as verified by a negative urine toxicology test) and provide tangible reinforcers each time the target behavior occurs. The reinforcers are most often monetary-based vouchers exchangeable for retail goods and services and the chance to win prizes of varying magnitudes. If the target behavior does not occur, the reinforcers are removed.

Contingency management is generally not provided as a stand-alone treatment for substance use disorders but instead is added to another treatment to improve outcomes. Contingency management is often combined with the community reinforcement approach in attempts to improve further the efficacy of the community reinforcement approach alone. An early study of voucher-based contingency management by Higgins et al. offered the community reinforcement approach along with contingency management to 13 consecutively admitted cocaine-dependent outpatients and offered 12-step–based drug counseling to the next 15 consecutively admitted cocaine-dependent outpatients. In the contingency management condition, vouchers worth a specific amount of money were provided whenever individuals submitted cocaine-negative urine samples. Significant group differences emerged in the percentage of participants who remained in treatment for 12 weeks, with 85% in the community reinforcement approach plus contingency management group and 42% in the 12-step group remaining in treatment for the entire period. Participants in the community reinforcement approach plus contingency management group also achieved significantly longer periods of objectively verified continuous cocaine abstinence, with 77% versus 25%, respectively, achieving a month or more of continuous abstinence.

Higgins et al. next conducted a 24-week randomized study comparing the same two treatments in a sample of 38 individuals, with half of them assigned to community reinforcement approach plus contingency management and the other half assigned to drug abuse counseling based on the 12-step model. Fifty-eight percent of the participants in the community reinforcement approach plus contingency management group completed treatment versus 11% of those in 12-step counseling. The groups also differed significantly on rates of continuous abstinence. Sixty-eight percent of participants receiving community reinforcement approach plus contingency management achieved 8 weeks of continuous abstinence compared with 11% in the 12-step counseling group. Group differences remained at 6-, 9-, and 12-month follow-up interviews. Participants who received community reinforcement approach plus contingency management were more likely to self-report cocaine abstinence over the past 30 days and to submit cocaine-negative urine samples compared with those who received 12-step counseling.

To isolate the specific contribution of contingency management to these beneficial outcomes, Higgins and colleagues next randomized 40 cocaine-dependent individuals to the community reinforcement approach alone or community reinforcement approach plus contingency management. Significantly more participants in the combined condition remained engaged in treatment for 24 weeks (75%) than in the community reinforcement approach-alone condition (40%). The longest duration of continuous abstinence differed between groups as well. Participants in the community reinforcement approach plus contingency management condition achieved an average of 11.7 (± 2.0) weeks of continuous abstinence from cocaine, whereas participants in the community reinforcement approach-alone condition achieved an average of 6.0 (± 1.5) weeks. These studies demonstrate that the community reinforcement approach plus contingency management is more effective than the community reinforcement approach alone for increasing the duration of abstinence. Furthermore, the benefits of community reinforcement approach plus contingency management persist up to a year beyond the end of the period during which vouchers are available.

Although contingency management adds to the benefits of the community reinforcement approach, the converse is also true: including the community reinforcement approach improves the benefits associated with contingency management alone. Higgins et al. assigned 100 cocaine-dependent individuals in a random fashion to either the combination of contingency management plus the community reinforcement approach or to contingency management alone. Participants who received the combined treatment remained in therapy longer, used cocaine less frequently during treatment, and reported a lower frequency of drinking to intoxication than did participants who received contingency management alone. Individuals treated with community reinforcement approach plus contingency management also evidenced improvements on other domains relative to individuals who received contingency management only. These included more days of employment, reduced depressive symptoms, and fewer hospitalizations and legal problems. Thus contingency management is an efficacious intervention for cocaine dependence, but it is most effective when administered in conjunction with the community reinforcement approach in this population.

Other studies have extended these benefits of community reinforcement approach plus contingency management to other substance-abusing populations. Bickel et al. randomized 39 opioid-dependent individuals to a usual-care condition or community reinforcement approach plus contingency management. During treatment, abstinence rates were significantly higher among individuals who received contingency management. Using a nonrandomized design, Schottenfeld et al. compared 117 opioid-maintained, cocaine- and opioid-dependent individuals who received either drug counseling or community reinforcement approach plus contingency management. Although retention and drug use did not differ between individuals receiving different forms of therapy in this report, engagement in community activities unrelated to drug use (e.g., parenting activities, employment, or planned recreational activities) was significantly associated with abstinence.

In the treatment of other drug use disorders such as nicotine, marijuana, or benzodiazepines, contingency management is typically applied as an adjunct to usual-care psychotherapies, rather than in conjunction with the community reinforcement approach. A variety of studies demonstrate that contingency management improves the treatment outcomes of marijuana-dependent individuals when added to motivational enhancement therapy or cognitive behavioral therapy. Contingency management is also efficacious in the treatment of nicotine dependence ^a

a References 2, 13, 21, 57, 58, 63.

and benzodiazepine use.

Two meta-analyses have demonstrated the therapeutic efficacy of contingency management in treating different substance use disorders. Across 30 studies comparing treatments with and without the addition of voucher-based contingency management, Lussier et al. found medium-sized group differences in length of abstinence from cocaine, opiates, tobacco, alcohol, and marijuana, with no significant difference in outcomes across specific drugs. More immediate delivery of reinforcement and higher reinforcement magnitude were associated with greater therapeutic benefit. In an independent analysis of 47 contingency management trials that used vouchers as well as other forms of reinforcement (e.g., cash and privileges such as take-home methadone doses), Prendergast et al. found that contingency management was most effective in reducing cocaine and opiate use. Smaller effects were noted with respect to reducing tobacco and polydrug abuse. Although both of these meta-analyses found benefits of contingency management, they included many studies that did not incorporate appropriate behavioral principles in the design of the reinforcement structure, such as frequent monitoring and reinforcement and escalating reinforcers with sustained behavioral change. The benefits of contingency management are greater in studies that utilize appropriate behavioral principles.