National Institute on Drug Abuse
Behavioral Therapies Development Program - Effective Drug Abuse Treatment Approaches
Innovative Day Treatment with Abstinence Contingencies and Vouchers
Homeless crack addicts were involved in state-of-the-art behavioral day treatment. Intervention included individual assessment and goal setting, individual and group counseling, multiple psycho-educational groups (didactic groups on community resources, housing, cocaine, HIV/AIDS prevention, groups to establish and review personal rehabilitation goals, relapse prevention, weekend planning, etc), client governed therapeutic community meetings in which patients reviewed contract goals and provided support and encouragement, transportation to and from shelters, and lunch. For the first two months, day treatment required daily attendance for 5.5 hours. Group therapy was scheduled three times per week and individual counseling was scheduled weekly. After two months of day treatment and at least two weeks of abstinence, participants graduated to a 4 month abstinent contingent work component that paid wages from which inexpensive, drug free, abstinence contingent housing could be rented.
Milby and colleagues compared this innovative day treatment to 'usual care' in a randomized controlled study with outcome variables measured at baseline, 2, 6, and 12 months. Usual care consisted of twice weekly individual counseling and 12-step groups, medical examinations and treatment, referral to community resources for housing and vocational services. Innovative day treatment followed by abstinence contingent work and housing was more effective than UC on alcohol use, cocaine use, and days homeless (Milby, 1996). However, the differential role of day treatment versus abstinent contingent work/housing in treatment were inseparable.
In a subsequent study, the intensive behavioral day treatment was refined by focusing individual goal formulation and evaluation to drive individual and group counseling activities and by adding a voucher system that reinforced nondrug related social and recreational activities. Each client had individually determined, objectively defined goals to address major problems identified at initial assessment. Goals were reviewed and modified weekly. Added structure systematically exposed homeless drug abusers (primarily crack abusers) to new sources of non-drug related reinforcers in a nondrug using social context. Abstinent contingent work and housing access during aftercare was retained from the previous study. In addition, an abstinence contingency for provided housing was added during initial day treatment. Results suggest that addition of abstinent contingent housing and work therapy improved drug abuse outcomes.
Milby, J.B., Schumacher, J.E., Raczynski, J.M., Caldwell, E., Engle, M., Michael, M., & Carr, J. (1996). Sufficient conditions for effective treatment of substance abusing homeless. Drug & Alcohol Dependence, 43:39-47
Milby, J.B., Schumacher, J.E., McNamara, C., Wallace, D., McGill, T., Stange, D., & Michael, M. (1996). Abstinence contingent housing enhances day treatment for homeless cocaine abusers. National Institute on Drug Abuse Research Monograph Series 174, problems of Drug Dependence, 1996: proceedings of the 58th Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. 77.
Schumacher, J.E., Milby, J.B., Caldwell, E., Raczynski, J.M., Engle, M., Michael, M., & Carr, J. (1995). Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine. Journal of Addictive Diseases, 14, 73-85.
Schumacher, J., Milby, J., Raczynski, J., Caldwell, E., Engle, M., Carr, J., and Michael, M. (1995). Validity of self-reported crack cocaine use among homeless persons in treatment. Journal of Substance Abuse Treatment, 12, 335-339.
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