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10.1146/annurev.clinpsy.2.022305.095219

Annu. Rev. Clin. Psychol. 2006. 2:411–34doi: 10.1146/annurev.clinpsy.2.022305.095219

Copyright c© 2006 by Annual Reviews. All rights reservedFirst published online as a Review in Advance on January 16, 2006

CONTINGENCY MANAGEMENT FOR TREATMENT

OF SUBSTANCE ABUSE

Maxine StitzerDepartment of Psychiatry and Behavioral Sciences, Johns Hopkins University School ofMedicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224;email: [email protected]

Nancy PetryDepartment of Psychiatry, University of Connecticut Health Center, Farmington,Connecticut 16130; email: [email protected]

Key Words incentives, vouchers, drug abstinence, medication compliance,behavioral therapy

■ Abstract Clinical research trials demonstrate the efficacy of contingency man-agement procedures in treating substance use disorders. Usually, reinforcement, inthe form of vouchers exchangeable for retail goods and services, is provided for drugabstinence in patients treated in psychosocial or methadone maintenance clinics. Re-cently, the types of reinforcers have been adapted to include lower cost alternatives, andreinforcement is being expanded to alter other target behaviors such as attendance attreatment, adherence to treatment goals, and compliance with medication. This chapterprovides an overview of the populations and behaviors to which contingency manage-ment approaches have been applied. It also reviews design features that appear criticalin the successful adaptation of the techniques. In addition, areas for future research aredescribed.

CONTENTS

INTRODUCTION TO CONTINGENCY MANAGEMENT . . . . . . . . . . . . . . . . . . . 412

Target Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

Reinforcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Contingent Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

REINFORCEMENT OF DRUG ABSTINENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Psychosocial Counseling Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414

Methadone Maintenance Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

Detoxification Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

REINFORCEMENT OF OTHER TARGET BEHAVIORS . . . . . . . . . . . . . . . . . . . . 422

Therapy Attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422

Treatment Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422

Medication Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

1548-5943/06/0427-0411$20.00 411

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412 STITZER � PETRY

INTERVENTION PARAMETERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

Schedules of Reinforcement: Escalating and Reset Features . . . . . . . . . . . . . . . . . . 425

Reinforcer Immediacy and Magnitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426

Shaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426

COMBINATION THERAPIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

NOVEL APPLICATIONS OF CONTINGENCY MANAGEMENT . . . . . . . . . . . . . 428

SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

INTRODUCTION TO CONTINGENCY MANAGEMENT

Contingency management (CM) treatments are derived from basic behavioral prin-ciples, particularly the principle that reinforced behaviors will increase in fre-quency. In the drug abuse treatment field, therapies must compete with the potentand immediate reinforcement provided by the abused drug itself. The applicationof CM in drug abuse treatment is based on providing tangible and immediatereinforcement that can effectively compete with drug reinforcement to promoteabstinence and alternative nondrug-related behaviors. From their origins in animaloperant conditioning research, these interventions have been adopted by clinicianswho typically provide a tangible reinforcer, such as a voucher exchangeable forretail goods and services, each time patients provide objective verification of adesired behavior such as drug abstinence. Although drug abstinence is of centralinterest as an outcome in drug abuse treatment, growing evidence suggests thatCM therapies can be expanded to behaviors beyond abstinence, and that a varietyof reinforcers can be used. The efficacy of CM interventions for retaining sub-stance abusers in treatment and enhancing abstinence has been demonstrated innumerous clinical trials (Petry 2000). Nevertheless, some basic procedures mustbe incorporated in the design of these interventions for them to be efficacious.

In this chapter, we provide an overview of CM and review evidence of itsefficacy. We detail the use of reinforcement for drug abstinence in a variety ofsettings and populations, and discuss how these techniques can be expanded toother behaviors. We also describe issues central to the design of an effective CMintervention and areas for future research.

Target Behaviors

The primary goal of drug abuse treatment in general, and of CM in particular, is toreduce or eliminate drug use behaviors. In CM interventions, the behavior targetedfor change must be measured frequently, and only reports that are objective, asopposed to subjective, can be usefully considered. Thus, when abstinence is thetarget behavior for reinforcement, drug use is generally monitored several times(e.g., three times) weekly because most urine monitoring systems can detect onlydrug use that has occurred over the prior 48–72 hours. Frequent testing is idealbecause it provides little opportunity for patients to use drugs without the test de-noting a positive sample, while at the same time, it provides patients with frequent

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CONTINGENCY MANAGEMENT REVIEW 413

opportunities to earn reinforcement if they are able to refrain from substance usefor a relatively short, 2–3 day period.

Reinforcers

Each time a patient tests negative for the targeted substance, the clinician providesthe patient with the reinforcer. The reinforcers used in CM interventions havevaried from money (Shaner et al. 1997), to vouchers exchangeable for retail goodsand services (Higgins et al. 1994), to the opportunity to win prizes of differentmagnitudes (Petry et al. 2000). In some settings, clinic privileges, such as take-home doses of methadone, are provided (Stitzer et al. 1992). Each of these types ofreinforcers has efficacy in reducing drug use, most likely because similar behavioralprinciples are employed in their design, including the contingent nature of thereinforcement.

Contingent Link

Learning occurs most rapidly whenever a desired behavior is immediately fol-lowed by its consequence. Thus, in teaching a young child to make his bed, areinforcer (money, candy) would ideally be provided each day immediately afterthe child makes the bed. If the bed is not made, no money or candy are given. Oncea new behavioral pattern is established, the parent may move to a more intermittentreinforcement schedule, such as awarding more money, or a day out at the movies,after about a week if the bed is made continuously during that period. Researchin behavior analysis demonstrates that behaviors that are ultimately reinforcedunder variable schedules are less likely to extinguish if reinforcement is omit-ted. Descriptions of rats lever-pressing thousands of times without reinforcement,for example, are noted (Ferster & Skinner 1957), as are descriptions of humansworking for many hours for a single drug reinforcer (McLeod & Griffiths 1983).

In CM interventions for substance abusers, the situation becomes a bit morecomplicated because reinforcement may not be provided for a behavior per se,but instead for the lack of one (nondrug use). Therapists certainly cannot followpatients around in the community and give vouchers continuously during times theysuccessfully refrain from using drugs. Instead, the submission of drug-negativespecimens is reinforced, a proxy for refraining from drug use for a several-dayperiod. As described below, these procedures are efficacious in reducing drug usein a number of settings.

REINFORCEMENT OF DRUG ABSTINENCE

Abstinence is a primary behavioral outcome in drug abuse treatment, since periodsof abstinence are associated with positive benefits both to the individual and tosociety. Controlled research reviewed below shows that CM procedures providingexternal reinforcement for evidence of drug abstinence can be highly effective for

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promoting sustained periods of abstinence, particularly while the interventions arein place. Natural recovery processes that take place during periods of sustainedabstinence, including gradual diminution of response to drug-related cues andlifestyle changes that provide alternative competing reinforcers, may then formthe mechanisms for longer-term recovery of addicted individuals. Reinforcementprinciples have been applied both in outpatient psychosocial counseling programsthat treat alcohol, marijuana, and stimulant abusers and in methadone maintenanceprograms that treat opioid abusers. The following sections review studies that havetargeted drug abstinence in these two types of settings.

Psychosocial Counseling Programs

Psychosocial counseling programs refer to clinics providing counseling and psy-chotherapy without methadone or other agonist pharmacotherapies. They typicallyoffer individual and group counseling of either a structured format (e.g., cognitive-behavioral therapy) or an eclectic approach.

STIMULANT TARGET; VOUCHER REINFORCERS Psychosocial counseling programshave been the focus of a number of CM studies, including one of the first voucherCM studies conducted at the University of Vermont. Higgins et al. (1994) treatedall cocaine-dependent patients with community reinforcement approach (CRA)therapy (Budney & Higgins 1998), an individualized and intensive intervention inwhich therapists may go out into the community to engage patients in treatmentand facilitate expansion of their nondrug-using networks. All patients left urinesamples twice weekly, which were screened for the presence of cocaine. Half ofthe patients (N = 20) were randomly assigned to receive CRA alone, and the otherhalf (N = 20) received CRA plus vouchers for every specimen that tested cocaine-negative. Voucher amounts escalated for each consecutive negative specimen, suchthat the first negative sample resulted in $2.50 in vouchers, the next sample $3.75,then $5.00 and so on. Over a 12-week period, patients could earn about $1000 ifthey provided all negative specimens. Vouchers could be spent upon retail goodsand services that were consistent with a drug-negative lifestyle, and were typicallyused for gift certificates, clothing, electronics, etc.

Patients who were randomly assigned to the voucher + CRA condition re-mained in treatment significantly longer and achieved greater durations of absti-nence from cocaine than did those assigned to receive CRA alone (Higgins et al.1994). Three-quarters of patients receiving CM completed the study, comparedwith 40% receiving CRA alone. Over half of those in the CM condition achievedat least two months of continuous cocaine abstinence versus only 15% in thenon-CM condition.

Higgins et al. (2000a) subsequently found that it was not just the availabilityof vouchers, but rather the contingent delivery of them, that improved outcomes.In that study, all cocaine-dependent patients again received CRA as the platformtherapy, but they also all received up to $1000 in vouchers. In one condition, the

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vouchers were contingent upon cocaine abstinence (N = 36), but in the other(noncontingent) condition (N = 34), patients received vouchers regardless of theoutcomes of their sample results. Provision of noncontingent vouchers resultedin similar proportions of patients remaining in treatment for six months (56%versus 53% in contingent and noncontingent, respectively). However, a higherproportion of those in the contingent versus the noncontingent condition achieved12 weeks of continuous abstinence during treatment. Thus, a longer period ofsustained abstinence was seen when vouchers were contingent upon providingnegative samples.

CM is also effective when used by other investigators and in different treatmentmodels. Jones et al. (2004) tested the efficacy of abstinence-contingent vouchers forpreventing relapse to cocaine use. After a brief residential stay, cocaine-dependentpatients were randomly assigned to conditions in which they could earn up to$1155 in abstinence-contingent (N = 103) or noncontingent (n = 96) vouchersduring a 12-week, once weekly outpatient phase. Significant benefits of contingentvouchers were found for the number of cocaine negative samples submitted anddays of continuous cocaine abstinence in this commonly used treatment model, inwhich detoxification is followed by aftercare.

STIMULANT TARGET; PRIZE REINFORCERS Other types of reinforcers have also beeninvestigated for reducing stimulant use in psychosocial treatment programs. Thisresearch extends beyond the university setting to community-based clinics, withan aim of reducing costs of the vouchers. Rather than earning escalating amountsof vouchers for successive negative specimens, patients earn the chance to draw aslip of paper from an urn, and each draw is associated with the chance of winninga prize. Only about half the slips result in a prize, as about 50% state, “Good job!”When prize slips are drawn, they are associated with three prize categories, in de-creasing probabilities: small $1 prizes (e.g., choice of fast food gift certificates, bustokens), large $20 prizes (e.g., watches, Walkmans), and jumbo $100 prizes (e.g.,TVs, DVD players, boom boxes). The overall cost of prizes per patient using thistechnique ranges from approximately $240 to $400 during a 12-week treatmentperiod.

Several studies of this approach have been conducted with cocaine-abusingpatients (Petry et al. 2004), including one comparing it to traditional voucherCM. Petry et al. (2006) randomly assigned 142 patients at three community-basedpsychosocial treatment programs to standard care as usual, standard care plus prizebowl reinforcement, or standard care plus voucher reinforcement. Patients in thetwo CM conditions remained in treatment significantly longer and achieved greaterdurations of abstinence compared with those in standard treatment alone. Althoughno statistically significant differences between the two CM conditions were noted,there was a trend toward greater improvements in the prize CM condition relativeto the voucher CM condition.

In an even larger, multisite trial conducted at eight clinics throughout the coun-try as part of the Clinical Trials Network (CTN; Petry et al. 2005), 415 stimulant

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users were randomly assigned to standard care or standard care plus the chanceto win prizes for submission of stimulant-negative specimens. About 35% of pa-tients in standard care remained in treatment throughout the 12-week study period,compared with 50% in the contingent condition. Only 12% of those in standardcare versus 26% in the CM condition achieved at least eight weeks of continuousabstinence. No differences in the percentages of negative samples were found, asmore than 88% of specimens in both conditions tested negative for stimulants.Thus, most patients were abstinent while they remained in treatment.

Higgins and colleagues have investigated the longer-term posttreatment effectsof voucher reinforcement targeted on cocaine abstinence. In one study (Higginset al. 2000a), the benefits of contingent versus noncontingent voucher reinforce-ment were apparent for up to 12 months after treatment ended, resulting in higherrates and longer durations of cocaine abstinence for those treated with contingentvouchers. Importantly, Higgins and colleagues (Higgins et al. 2000b) have shownthat the likelihood of posttreatment abstinence is directly related to duration of ab-stinence achieved during treatment. This observation emphasizes the importanceof during-treatment abstinence as a primary treatment goal. It also supports thespeculation that mechanisms for long-term beneficial effects of CM lie in nat-ural recovery processes and lifestyle changes that take place during periods ofprolonged abstinence.

ALCOHOL TARGET Alcohol is the most common substance for which patients seektreatment at psychosocial counseling programs, but few studies of CM have beenconducted in this population. The primary reason for the paucity of CM trialsin alcohol-dependent patients relates to technological limitations in objectivelyverifying abstinence. Breath, urine, and blood tests can only detect alcohol useover a brief period, such as four to eight hours. To accurately gauge (and reinforce)alcohol abstinence would require testing two to three times daily, a schedule thatis unfeasible in most settings.

Only a few studies have evaluated the efficacy of CM in primarily alcohol-abusing populations (e.g., Miller 1975, Petry et al. 2000). Miller (1975) randomlyassigned 20 individuals with multiple public drunkenness offenses either to stan-dard care or to a CM intervention that provided basic goods and services contingentupon sobriety. This intervention resulted in substantial reductions in public drunk-enness arrests and alcohol consumption. In a larger trial of 42 patients, Petry et al.(2000) applied the prize-CM approach to alcohol-dependent veterans receivingintensive outpatient treatment at a Veterans Administration hospital. More than80% of those assigned to the CM condition remained in treatment throughout theeight-week study period versus 22% of those in the standard care condition. Fur-ther, as shown in Figure 1, 69% of those in the CM versus 39% in the standardcare condition reported no alcohol use through the end of treatment.

MARIJUANA TARGET Detection of marijuana abstinence suffers from the oppositeproblem as alcohol: In chronic marijuana users, samples can test positive for several

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Figure 1 Relapse to alcohol use during an eight-week treatment period. Abstinence

survival data are shown for patients who received a prize-draw contingency manage-

ment (CM) intervention based on negative breath-alcohol readings in an outpatient

psychosocial counseling program (N = 19) and those who received usual-care coun-

seling without the CM intervention (N = 23). (From Petry et al. 2000)

weeks after use ceases. Thus, reinforcing patients for initial efforts at abstinenceis much more difficult. Despite these technical issues, CM interventions can beefficacious in reducing marijuana use. Budney et al. (2000) randomly assigned60 marijuana abusers to motivational enhancement therapy (MET) alone, MET incombination with cognitive-behavioral therapy (CBT), or the two psychotherapiesplus voucher CM (maximum of $570 over 12 weeks). To address the potentiallylong latency to achieve negative urine tests, vouchers did not begin until week 3of the 14-week study. Results were striking: Those in the CM condition achievedan average of 4.8 weeks of continuous abstinence versus 2.3 and 1.6 weeks inthe two non-CM conditions. Thus, even with substantial modifications such asreduced earnings and delay in start of reinforcement, CM was highly efficaciousin reducing marijuana use.

CIGARETTE SMOKING TARGET Offering payments contingently for evidence ofsmoking reduction (i.e., reduced breath carbon monoxide readings) is an effectivemethod to alter cigarette-smoking behavior in general samples of smokers who arenot trying to quit (Stitzer & Bigelow 1983, 1984). More recently, CM approaches

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have been used to engender periods of smoking abstinence in nonquitters (Alessiet al. 2004, Heil et al. 2003). Contingent reinforcement techniques could be used insmoking cessation programs as well, and recently the technique has been appliedto substance abusers who wish to quit smoking (Shoptaw et al. 2002).

These studies suggest that CM holds promise as an aid to smoking cessationtreatment. However, technical issues need to be worked out, including identifica-tion of feasible and appropriate biological markers for verifying smoking absti-nence. Breath carbon monoxide is convenient to measure, but it requires frequentmonitoring due to its very short half-life. Cotinine, nicotine’s major metabolite,can be measured in urine or saliva, has a longer (20-hour) half-life and is a highlysensitive index of nicotine intake (Benowitz 1996). Previously, this metabolic by-product required specialized laboratory technology to measure, but new dipsticktechnologies (Gariti et al. 2002) hold promise for improving feasibility and mayhave useful application in CM for smoking cessation.

Methadone Maintenance Programs

Methadone is a long-acting, orally effective opioid medication that can be used totreat opioid dependence. It relieves withdrawal symptoms and attenuates effectsof short-acting opioids through cross-tolerance. Although methadone is a highlyefficacious treatment for opioid users, the continuing use of other drugs duringtreatment is a serious problem, but one that can be addressed with CM.

STIMULANT DRUG TARGET Some of the initial studies of voucher reinforcementwere conducted within methadone clinics because many methadone patients abusestimulants in addition to opioids. For example, Silverman et al. (1996) utilized ayoked-control design similar to that of Higgins et al. (2000a). All 40 patients in thisstudy received standard methadone therapy, but half were randomly assigned to acondition in which vouchers (maximum of $1155 over 12 weeks) were contingentupon cocaine abstinence, while the other half were assigned to a noncontingentvoucher condition. More than 80% of the patients in both groups remained in treat-ment for the entire 12-week trial. About half of the patients in the voucher conditionwere able to achieve eight or more weeks of continuous cocaine abstinence com-pared with none who achieved this duration of abstinence when vouchers weredelivered independent of behavior.

Other studies add considerable weight to the evidence that CM is efficacious inreducing stimulant use during methadone treatment and also have tried to identifyimproved intervention parameters. One study (Silverman et al. 1998) replicatedprior observations that vouchers could significantly reduce cocaine use duringtreatment, but found that adding up to twelve $50 bonuses during the first sixweeks of treatment based on early abstinence initiation did not improve outcomes.

More recently, Silverman and colleagues (2004) examined the additive benefitsof abstinence-contingent take-homes and voucher reinforcers in a study that ex-tended the intervention duration to 52 weeks. Methadone patients (N = 78) with

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Figure 2 Percent cocaine-negative samples submitted during a 10-week baseline

period and a 52-week intervention. Methadone-maintained patients with evidence of

ongoing cocaine use were randomly assigned in week 10 to receive one of three inter-

ventions: (a) take-homes contingent on opioid- and cocaine-negative samples plus

vouchers contingent on cocaine negative samples, (b) contingent take-home rein-

forcers only, or (c) usual-care methadone maintenance with no contingent reinforcers

(N = 26 per group). (Adapted from Silverman et al. 2004)

evidence of ongoing cocaine use were randomly assigned to conditions where theycould (a) earn methadone take-homes (three per week) for providing opioid- andcocaine-free urines, (b) earn take-homes as above and also vouchers (maximumof $5500 over 52 weeks) for cocaine-free urines, or (c) participate in usual carewithout the opportunity to earn abstinence-contingent incentives. As illustrated inFigure 2, results were impressive, with significant between-group differences inoverall rates of cocaine-negative urines submitted. In addition, 42% of participantswere continuously abstinent from stimulants for six months or more in the take-home plus voucher group as compared with 8% in the take-home only and 0% inthe standard-care groups. Further, initiation of long periods of sustained abstinencewas observed across the first nine months of the trial. These data suggest a benefitof long-term implementation of CM with methadone patients.

The prize CM technique is also efficacious in cocaine-using methadone patients.Petry et al. (2005) randomly assigned 77 cocaine-abusing methadone patients tostandard treatment or standard treatment plus prize CM. Patients receiving CMhad about twice the rate of cocaine abstinence as those in the standard condition

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(35% versus 17%, respectively). A similar study was conducted in six methadoneclinics throughout the country as part of the National Drug Abuse TreatmentClinical Trials Network. Peirce et al. (2006) randomly assigned 388 cocaine-usingmethadone patients to standard treatment alone or with prize CM. Patients couldearn up to $400 during a 12-week study if their samples tested negative. Theoverall proportion of cocaine-negative samples submitted in the CM group (54%)was significantly greater than in the standard group (37%), and the odds that astimulant-negative sample would be submitted during treatment were doubled bythe CM intervention.

OPIOID DRUG TARGET Other CM studies have focused explicitly on opioid useduring methadone treatment. Some of these studies were conducted prior to the ad-vent of vouchers and utilized cash or clinic privileges such as take-home methadonedoses as reinforcers. For example, Stitzer et al. (1980) showed that patients sub-mitted fewer opioid-positive samples during periods when they could earn moneyor take-homes for negative samples. Silverman et al. (1996b) showed that opioiduse could be dramatically suppressed by a voucher CM program (maximum of$1155 over 12 weeks), and Preston et al. (2000) investigated the separate andcombined benefits of higher methadone doses and CM in 120 methadone patients.Contingent vouchers (maximum of $554 over eight weeks) and higher methadonedose (70 mg versus 50 gm) each significantly increased the percentage of opioid-negative specimens, but the combined intervention did not have additive benefits.

POLYDRUG TARGET Because of the high rates of polydrug use observed inmethadone patients, some studies have applied contingencies to abstinence frommultiple drugs concurrently. Generally, these procedures are not as efficacious aswhen reinforcement is provided for abstinence from one drug at a time (Downeyet al. 2000, Griffith et al. 2000, Piotrowski et al. 1999). Most likely, reduced efficacyis related to the difficulty of abstaining from several drugs simultaneously amongthose individuals who use many types of drugs concurrently. Even when cocaineabstinence alone is reinforced in methadone patients, over half the sample may beunable to provide even a single cocaine-free sample (Dallery et al. 2001, Silvermanet al. 1996a). This situation is likely exacerbated in those who use multiple drugs.

Nevertheless, there have been some successful demonstrations of CM applica-tion to polydrug use targets in methadone patients. Stitzer et al. (1992) showedthat abstinent-contingent, as compared with noncontingent, methadone take-homeprivileges resulted in more patients showing sustained reductions in drug useeven though the contingency involved multiple drugs (opioids, cocaine, benzo-diazepines) and required a relatively long (two-week) period of abstinence prior toreceipt of the reinforcer. Some schedules that use bonuses to reinforce multidrugabstinence have also been successful. Petry & Martin (2002) devised a CM sched-ule in which patients earned a single draw if their samples tested negative for eithercocaine or opioids, and bonus draws when they were abstinent from both drugsconcurrently. This intervention was successful in simultaneously reducing use of

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both drugs. In the CTN study of prize CM (Peirce et al. 2006), methadone patientswere required to be abstinent from both alcohol and stimulants to earn prizes, withconcurrent opioid abstinence resulting in additional bonus draws. Both stimulantand opioid abstinence increased in the CM relative to the non-CM condition.

Several studies have shown that reductions in nontargeted drugs can be observedwhen reinforcement is directed toward a single drug. Thus, opioid use may declinewhen cocaine is the target of intervention (e.g., Silverman et al. 1996a, 2004), andcocaine use has declined when opioids are targeted (Robles et al. 2002). Additionalresearch is needed to determine whether bonuses further reduce use of secondarydrugs beyond the spontaneous reductions seen when a single drug is targeted.

Detoxification Programs

While methadone maintenance is considered the optimal treatment for most opioid-dependent patients, short-term medically supervised detoxifications are used clini-cally to ameliorate withdrawal during the initial stage of abstinence. Several studieshave demonstrated the efficacy of CM procedures for improving outcomes during(though not necessarily after) detoxification. In one early study (Higgins et al.1986), opioid-dependent patients (N = 58) in a 13-week methadone taper wererandomly assigned to one of three conditions, two of which involved the oppor-tunity to request and receive up to 20-mg daily dose increases during the taperperiod. Relapse was seen in both those who could not request the dose increaseand in those who could request an increase independent of their urine test results.In contrast, those who could request the increase only if their sample tested neg-ative for opioids had significantly fewer opioid-positive samples during treatmentand showed little evidence of relapse. This study suggests an inexpensive strategyfor suppressing relapse during a methadone dose taper while potentially tailoringthe speed of the taper to the ability of patients to maintain abstinence.

Another study (Robles et al. 2002) utilized vouchers to reduce relapse duringa 10-week methadone dose taper. Vouchers (maximum of $2232 over 22 weeks)for opioid-free samples were available both before, during, and after the taper. Al-though the intervention by no means eliminated relapse, rates of opioid-negativeurines were significantly higher among those who received vouchers contingenton opioid abstinence than among those who received noncontingent vouchers(74% versus 35% negative samples, respectively). Bickel et al. (1997) also foundthat voucher CM for opioid abstinence (maximum earnings of about $660) im-proved outcomes during a 23-week buprenorphine detoxification. Both retentionand during-treatment abstinence were significantly increased by CM. Finally, Katzet al. (2004) offered a one-time $100 bonus for completion of a one-week outpa-tient detox with an opioid- and cocaine-negative urine result; they showed a smallbut statistically significant effect of CM in terms of percent negative samples sub-mitted on the last day of the detoxification.

Although therapeutic benefits of detoxification are generally limited in the ab-sence of some kind of continuing treatment, the studies reviewed here provide

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support for the potential utility of CM approaches in helping more patients tosuccessfully complete detoxification protocols.

REINFORCEMENT OF OTHER TARGET BEHAVIORS

Abstinence from illicit drugs and alcohol may be considered the most importantgoal of drug abuse treatment. However, many other behaviors are legitimate targetsof interventions. These behaviors, many of which are critical for long-term healthand psychosocial outcomes, can be positively influenced by CM interventions, asreviewed in the following section.

Therapy Attendance

As noted earlier, CM procedures that reinforce abstinence in psychosocial counsel-ing programs also tend to have beneficial effects in improving retention, most likelybecause the requirement of leaving samples necessitates attendance. However, sim-ply reinforcing attendance alone can have benefits. In methadone patients, Stitzeret al. (1977) and Kidorf et al. (1994) successfully used take-home methadone dosesto reinforce therapy attendance. Similarly, Rhodes et al. (2003) found that prize-based CM improved on-time counseling session attendance in methadone patients.However, CM procedures are not always effective in enhancing attendance, andattendance may not necessarily be associated with reduction in drug use (Kidorfet al. 1994). In a CM study with pregnant substance abusers, Svikis et al. (1997)noted a modest improvement in attendance of women enrolled in a psychosocialcounseling modality when $5 or $10 per day was offered but not when $0 or $1was available. Jones et al. (2000) found little benefit of a low-magnitude vouchersystem ($5 per day on the first seven days of outpatient treatment), regardless ofwhether vouchers were contingent upon attendance alone or abstinence. In a laterstudy, however, Jones et al. (2001) found better attendance and drug use outcomeswhen pregnant women were offered reinforcement under an escalating voucherschedule (maximum earnings of $525) during their first two weeks of treatment.The less favorable outcomes in some studies may relate to the low magnitudes ofreinforcement provided.

Treatment Plans

Because of the array of problems encountered by drug-abusing patients, somestudies have applied reinforcement contingent upon completion of goal-relatedactivities (Bickel et al. 1997, Iguchi et al. 1997). For example, patients maydecide upon three activities each week that are related to their treatment goals.These activities could include attending a medical appointment if the goal isto improve health, going to the library with their child if the goal is to im-prove parenting, or filling out a job application if the goal is to obtain employ-ment. If patients successfully accomplish these activities and provide objective

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documentation of their completion, they would earn vouchers or draws from afishbowl.

Some data suggest that involvement in these activities may reduce drug use.In a study of polydrug-using methadone patients, Iguchi et al. (1997) found thata condition in which vouchers were provided contingent only upon compliancewith activities was more effective in reducing drug use than a condition in whichabstinence alone was reinforced. However, the basic design of that study wasrecently replicated in a psychosocial counseling program, with different results(N.M. Petry, S.M. Alessi, K.M. Carroll, T. Hanson, S. McKinnon, et al., underreview). In this study, 131 patients were randomly assigned to treatment as usual,prize CM for submission of drug-negative samples, or prize CM for completionof goal-related activities. The total number of draws and magnitudes of expectedprizes were equivalent in the two CM conditions. Although both CM interventionsimproved outcomes relative to standard treatment alone, the CM-abstinence con-dition resulted in greater retention and more abstinence than did the CM-activitycondition. Thus, in this study, reinforcing abstinence was the better method for im-proving outcomes. Nevertheless, future research should explore interventions thatcombine use of different behavioral targets to see whether additive or synergisticeffects might be achieved. This is particularly relevant in light of the hypothesizedrole that may be played by competing reinforcers derived from a nondrug lifestylein supporting long-term abstinence.

Medication Adherence

Another class of therapeutically important behaviors that can be improved throughCM is medication adherence. Adherence to medication regimens is particularlypoor among substance abusers (e.g., Cox et al. 1996). For example, an individualwho consistently ingests the opioid antagonist naltrexone cannot experience opi-oid effects or relapse to dependence, but adherence to naltrexone is poor (Natl.Res. Counc. 1978). Several studies have shown that reinforcing naltrexone con-sumption can greatly increase adherence. Preston et al. (1999) compared retentionand opioid drug use among 57 recently detoxified opioid-dependent patients whoreceived voucher reinforcers (maximum of $1155 over 12 weeks) for ingestingnaltrexone three times per week under observation at the clinic with those who re-ceived yoked vouchers independent of their naltrexone ingestion or who receiveda naltrexone prescription after their detoxification with no contingencies (usualcare). The mean number of naltrexone doses ingested was significantly greater forthe contingent reinforcement (21.4 doses) than for noncontingent (11.3 doses) orusual-care (4.4 doses) groups, and drug use outcomes were closely tied to whetheror not naltrexone had been ingested. As shown in Figure 3, retention to the endof treatment, at 50%, 25%, and 5% for the three groups, respectively, was re-lated to the amount of naltrexone ingested rather than to the amount of vouchermoney received, which was equated for the contingent and noncontingent vouchergroups.

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0

20

40

60

80

100

0 3 6 9 12 15 18 21 24 27 30 33 36

No Voucher Group

Contingent GroupNon-Contingent Group

Treatment Retention

Study Visit0 1 2 3 4 5 6 7 8 9 10 11 12Study Week

% R

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in

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Figure 3 Percentage of opioid-dependent patients remaining in outpatient treatment during

a 12-week intervention. Data are shown for patients receiving vouchers contingent on naltrex-

one ingestion (N = 19), noncontingent vouchers yoked to performance of contingent group

members (N = 19), or usual care consisting of naltrexone prescription with no contingencies

on ingestion (N = 20). (From Preston et al. 1999)

Similarly, Carroll et al. (2001) randomized patients to two groups that couldearn vouchers (maximum of $561) for ingesting naltrexone and providing opioid-negative urines (N = 85). These patients had significantly better retention anddrug-use outcomes than patients (N = 44) who received standard supervisednaltrexone. In a follow-up study, Carroll et al. (2002) found doubling vouchervalues did not further improve outcomes.

CM techniques may also be useful for improving adherence to HIV regimes.Rigsby and colleagues (2000) found that contingent monetary reinforcement com-bined with a personalized cue reminder plan resulted in better adherence to an HIVpharmacotherapy regimen than did the cue reminder plan alone or nondirective in-quiries about medication ingestion. Seal et al. (2003) compared the effectiveness ofclinical outreach versus monetary incentives ($20/month) for adherence to a three-dose hepatitis B vaccine regimen. Only 23% in the outreach group completed thevaccine regimen compared with 69% in the CM condition.

In sum, CM can be effective for reinforcing medication adherence, and thisin turn may assist patients in achieving and maintaining drug abstinence and/orimproving medical and psychiatric conditions. However, some technical issuesneed to be addressed before this approach is implemented widely, especially for

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medications that require doses be ingested away from the clinic such that ingestioncannot be directly monitored and immediately reinforced.

INTERVENTION PARAMETERS

The preceding sections have documented the wide array of behaviors that can bemodified using CM techniques and have noted that a number of different reinforcersare efficacious in altering behaviors of substance abusers. Despite this heterogene-ity, several technical commonalities are noted in successful CM interventions, asdetailed below.

Schedules of Reinforcement: Escalating and Reset Features

Both voucher and prize CM studies have applied escalating schedules of rein-forcement with resets back to low levels of reinforcement following a lapse to in-appropriate behavior, a strategy designed to reinforce sustained behavior change.Specifically, as patients achieve longer periods of abstinence, the value of thevouchers or number of draws increases. By the end of the 12-week treatmentperiod in Higgins’s studies (1994, 2000, 2003), for example, patients could earnover $30 for each drug-free urine specimen. Similarly, in the prize CM procedure,patients can earn up to 10–15 draws. If a sample is positive, refused, or missed(e.g., unexcused absence), the next negative sample provided results in a reset to$2.50 in vouchers or one draw from the fishbowl.

Eliminating the escalation feature and delivering a constant rate of reinforce-ment may make the voucher system less expensive and easier to implement. A studyby Roll et al. (1996) compared in cigarette smokers the escalating approach to onethat provided a constant rate of reinforcement, with both procedures providingequivalent total amounts of reinforcement. Although both schedules engenderedsimilar amounts of overall abstinence, the escalating system resulted in longerperiods of continuous abstinence, which in turn have been associated with goodlong-term outcomes (Higgins et al. 2000b, Petry et al. 2006). These results sug-gest that an escalating system may be necessary for inducing significant periodsof sustained abstinence, at least initially. Once behavior change has occurred, andsustained abstinence is ongoing, the value of the reinforcer may be reduced (e.g.,$1 lottery ticket) without a detrimental impact on outcomes.

The importance of engendering stable initial abstinence was highlighted in astudy by Kirby et al. (1998), where few cocaine-dependent patients initiated ab-stinence under a traditional escalating schedule. However, much better outcomeswere achieved in this population with a schedule that provided higher-valued re-inforcers initially for each negative sample and then tapered the density of rein-forcement using a fixed ratio schedule (i.e., requiring an increasing number ofconsecutive negative urines to receive the reinforcer). Future studies should eval-uate systematically and in a variety of populations the reinforcement parameters

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that can engender abstinence in the largest number of patients as well as when,and by how much, reinforcer magnitudes can be reduced without compromisingefficacy after stable abstinence is achieved.

Reinforcer Immediacy and Magnitude

Learning occurs best when each time the target behavior is exhibited it is followedby its consequence without delay (e.g., Zeiler 1977). Voucher programs use thisbehavioral principal by providing vouchers right after submission of a negativespecimen. Moreover, samples are screened within minutes of collection, and datasuggest that onsite testing systems engender greater abstinence than sending sam-ples offsite for testing (Schwartz et al. 1987). Similarly, draws from the fishbowlor exchange of vouchers for retail items occur with minimal delay, 2–3 days fromrequest. Meta-analyses demonstrate that immediacy of reinforcement appears tobe linked to effect sizes in CM studies (Griffith et al. 2000).

Behavior is determined not only by the rate of reinforcement but also by itsmagnitude (Catania 1966), and studies of CM likewise find that magnitude ofreinforcement affects outcomes. Stitzer & Bigelow (1983, 1984) found that nico-tine abstinence increased as a function of the magnitude of the reinforcer, rangingfrom $0 to $12 per day. Silverman et al. (1999) found that some cocaine-usingmethadone patients who were “treatment resistant” at standard voucher amountsachieved abstinence if amounts were increased threefold. Dallery et al. (2001)noted a direct relationship between voucher amounts and abstinence in anotherstudy of methadone patients. These studies all suggest that larger-magnitude rein-forcers may improve outcomes. Yet, some studies employing low-magnitude re-inforcers have demonstrated positive effects. Rowan-Szal et al. (1994) found thatstars exchangeable for $5 items reduced drug use. Petry et al. (2000, 2002, 2004,2005, 2006) found that prize systems based on intermittent reinforcement reducedalcohol, cocaine, and opioid use despite relatively low overall cost. Thus, whenprinciples associated with learning are applied, positive outcomes may be achievedwith lower-magnitude reinforcers. However, more research is needed to identifycharacteristics of patients who can benefit from low-magnitude reinforcers versusthose that require higher-magnitude reinforcers for effective behavior change. Forexample, there is currently no evidence to indicate that individuals with lower ver-sus higher income levels differentially benefit from CM interventions. However, itmay be the case that income status could influence the reinforcer magnitude thatis effective with a given individual.

Shaping

Another principle central to establishing new behavioral patterns is to reinforcesuccessive approximations, or shaping. For example, in teaching lever-press be-havior, a rat may be reinforced initially for sniffing the lever. As the rat beginsto sniff the lever more frequently, eventually he will lean on it and press it.Each gradual approximation toward the lever-press response is reinforced. Simi-larly, in establishing a pattern of drug abstinence, substance abuse clients can be

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reinforced for approximations of abstinence. Preston et al. (2001) showed that aninitial “shaping” procedure that reinforced reductions in urinary cocaine metabo-lite during the first three weeks of an eight-week intervention led to higher ratesof abstinence during a subsequent abstinence-based reinforcement phase, possiblybecause the shaping procedure allowed more participants to earn reinforcers andthus come into contact with the benefits of the incentive program.

Shaping procedures may be particularly efficacious in difficult-to-treat patients.Robles et al. (2000) developed the “brief abstinence test,” which provides a $100voucher contingent upon quantitative urinalysis evidence of recent (two-day) co-caine abstinence. Decrease in urinary benzoylecgonine concentration over the two-day test was seen in 94% of patients when the reinforcer was available, comparedwith 46% and 48% with decreasing concentrations during a comparable period inthe weeks preceding and following the abstinence test. Similarly, urinalysis criteriafor cocaine abstinence was met by 84% of study participants when the reinforcerwas available compared with only 36% and 32% meeting abstinence criteria dur-ing the weeks preceding and following the test. Although this procedure appearsuseful for initiating abstinence in cocaine users, its clinical utility has yet to bedemonstrated (Katz et al. 2002, Sigmon et al. 2004).

COMBINATION THERAPIES

One new direction in the field of CM research is to examine how CM may ad-ditively or synergistically improve outcomes when combined with pharmacother-apies or other psychotherapies. Higgins’s original voucher reinforcement studiescombined CM with an intensive behavioral therapy based on the Community Re-inforcement Approach (Budney & Higgins 1998). Higgins has now examined theseparate and combined efficacy of these major components of his multicomponenttreatment. One recent study (Higgins et al. 2003) showed that combined treatmentwith voucher reinforcers and CRA therapy produced better outcomes both duringand after treatment than the voucher reinforcement alone. For example, six-monthtreatment retention rates were 65% with the combined treatment versus 33% withvouchers alone. Cocaine use was lower during (but not after) treatment with thecombined therapy compared with vouchers alone, and other outcomes includingalcohol use and employment were also superior both during and after treatmentwith the combined approach. Thus, the study provides evidence of an additive ben-efit for combining CM with an intensive behavioral counseling program. However,studies in methadone populations that used a different type of counseling have notreached the same conclusion.

Rawson et al. (2002) examined the separate and combined effects of voucherreinforcement and cognitive-behavioral therapy (CBT) for improving cocaine ab-stinence outcomes in methadone-maintenance patients. The CM intervention wasmore effective than CBT for reducing cocaine use during treatment, but bothinterventions were equally effective (and superior to no treatment control) at 6-and 12-month follow-ups, with no additive effects of the interventions noted.

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A similar study by Epstein et al. (2003), also conducted in cocaine-usingmethadone-maintenance patients, also found significantly better during-treatmentresults when CM was implemented than when it was not, but the combinationof CM and CBT produced better outcomes than did other treatments at someposttreatment evaluation time-points. More research is needed to resolve thesediscrepant results across studies, and this is an important area of investigation forunderstanding the mechanisms of behavior change underlying long-term absti-nence outcomes when external reinforcers are used during CM interventions topromote periods of sustained abstinence.

Voucher incentives can also be used as a behavioral platform in pharmacother-apy studies (e.g., Jones et al. 2004). This strategy has the advantage of stabiliz-ing and equating external motivation for abstinence across all treated patients.Kosten et al. (2003), for example, used a four-cell design to examine desipramine(DMI; 150 mg/day) versus placebo combined with contingent (CM; maximum of$738 over 12 weeks for opioid- and cocaine-negative urines) versus noncontin-gent vouchers as treatments to reduce opioid and cocaine use in buprenorphine-maintained outpatients. An additive effect was found in that participants receivingthe combined treatment (DMI + CM) submitted significantly more opioid- andcocaine-free urines during treatment than did members of any other treatmentgroup. This suggests that combining CM with medication treatments may be agood strategy for enhanced treatment effectiveness. However, additional researchwould be needed in order to identify conditions under which the beneficial effectsof various combined therapies are or are not apparent.

NOVEL APPLICATIONS OFCONTINGENCY MANAGEMENT

As the principles of CM have become more widely accepted within both theresearch and treatment communities, novel applications have emerged that aredesigned to translate these principles into programs that can be integrated withongoing community treatment models and community resources. Milby et al.(1996, 2000) have developed and tested a comprehensive treatment program thatincorporates principles of CM while addressing basic needs of homeless cocaineabusers. In the comprehensive program, all patients can participate in an intensiveday-treatment program that focuses on skills training and goal setting. In addition,patients may be able to receive program-supported housing and employment in thecommunity, with the latter benefits contingent upon evidence of drug abstinence.Two randomized evaluation studies have been conducted. One study (Milby et al.1996) showed that day treatment with contingent housing and work producedbetter outcomes on measures of both drug use and homelessness than did usualcare delivered in a different program that provided twice weekly counseling andreferral services. A second study, as shown in Figure 4, revealed that the programincluding contingent housing and work produced better outcomes than did theintensive day-treatment program alone (Milby et al. 2000).

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Figure 4 Percentage of patients drug abstinent at two and six months after treat-

ment enrollment. Data are shown for those who received intensive day treatment only

(N = 54) versus day treatment with contingent access to program-sponsored housing

and employment (N = 56). Drug abstinence was defined as urines testing negative for

cocaine, marijuana, alcohol, amphetamine, morphine, and benzodiazepines. (Adapted

from Milby et al. 2000)

Another variation on the theme of intensive day treatment with contingent ac-cess to community resources is a medication-free outpatient treatment program(reinforcement-based therapy) for inner-city heroin abusers developed at JohnsHopkins University School of Medicine. This program provides individual coun-seling based on the community reinforcement approach (Budney & Higgins 1998).Those who remain drug-free can also receive rent for community recovery hous-ing, help with finding a job, and access to a daily recreation program designed toexpose participants to alternative sources of nondrug reinforcement in the commu-nity. This treatment, implemented with heroin abusers exiting medically supporteddetoxification, produced significantly better outcomes compared with a usual careintervention in which patients exiting detox are referred to community treatmentprograms for aftercare (Gruber et al. 2000, Jones et al. 2005).

Finally, Silverman and colleagues have developed a novel and innovative appli-cation of CM in which drug abusers are allowed to participate in paid job trainingor to work in a program-operated data entry business, but can only earn salaryfor work on days when they have delivered opioid and cocaine-free urine samplesat the program. In this novel conceptualization of CM, earned salary is used asthe contingent benefit, with the opportunity to work and earn salary being closely

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tied to and contingent upon abstinence. The program has demonstrated efficacy forsustaining both attendance and abstinence at six-month (Silverman et al. 2001) andthree-year (Silverman et al. 2002) evaluations. The idea of integrating abstinencerequirements into employment could be incorporated into employment or trainingprograms operated by treatment systems. Importantly, it is also an approach thatmay be acceptable for adoption by community-based employers.

SUMMARY AND CONCLUSIONS

CM interventions continue to demonstrate efficacy and utility for improving drugabuse treatment outcomes. Their ability to promote periods of sustained absti-nence has been documented for stimulants, alcohol, and marijuana when deliveredin the context of psychosocial counseling treatment programs and for stimulants,opioids, tobacco, and polydrug use when delivered in the context of methadonetreatment programs. Further, methodologies that employ principles of intermittentreinforcement have now been developed and tested that can reduce the cost ofCM interventions, and the effectiveness of these lower-cost interventions has beendocumented in large multisite clinical trials implemented in community treatmentprograms. The principles of CM have been effectively applied to other therapeuticbehaviors such as attendance, goal performance, and medication adherence. Fur-ther, novel applications have been developed that integrate CM into communitytreatment and employment-based models, thus expanding their potential therapeu-tic application.

Overall, the application of CM principles to the treatment of drug abuse hasaltered the landscape and conceptualization of treatment intervention. Researchon CM interventions continues to grow and thrive. Future research will no doubtimprove the efficacy and reach of these interventions by clarifying optimal in-tervention parameters, by continuing to develop models tailored to the needs ofspecial populations, by translating contingency management principles into pro-grams feasible for adoption by community treatment providers and other agencies,and by better understanding the underlying mechanisms of short- and long-termbehavior change associated with the use of CM.

The Annual Review of Clinical Psychology is online athttp://clinpsy.annualreviews.org

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P1: JRX

February 24, 2006 16:34 Annual Reviews AR271-FM

Annual Review of Clinical PsychologyVolume 2, 2006

CONTENTS

THE HISTORY AND EMPIRICAL STATUS OF KEY PSYCHOANALYTIC

CONCEPTS, Lester Luborsky and Marna S. Barrett 1

DOCTORAL TRAINING IN CLINICAL PSYCHOLOGY, Richard M. McFall 21

METHODOLOGICAL AND CONCEPTUAL ISSUES IN FUNCTIONAL

MAGNETIC RESONANCE IMAGING: APPLICATIONS TO

SCHIZOPHRENIA RESEARCH, Gregory G. Brown and Lisa T. Eyler 51

THE USE OF STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOR (SASB) AS

AN ASSESSMENT TOOL, Lorna Smith Benjamin, Jeffrey ConradRothweiler, and Kenneth L. Critchfield 83

REINTERPRETING COMORBIDITY: A MODEL-BASED APPROACH TO

UNDERSTANDING AND CLASSIFYING PSYCHOPATHOLOGY,Robert F. Krueger and Kristian E. Markon 111

WOMEN’S MENTAL HEALTH RESEARCH: THE EMERGENCE OF A

BIOMEDICAL FIELD, Mary C. Blehar 135

POSTTRAUMATIC STRESS DISORDER: ETIOLOGY, EPIDEMIOLOGY, AND

TREATMENT OUTCOME, Terence M. Keane, Amy D. Marshall,and Casey T. Taft 161

THE PSYCHOPATHOLOGY AND TREATMENT OF BIPOLAR DISORDER,David J. Miklowitz and Sheri L. Johnson 199

ATTEMPTED AND COMPLETED SUICIDE IN ADOLESCENCE,Anthony Spirito and Christianne Esposito-Smythers 237

ENDOPHENOTYPES IN THE GENETIC ANALYSES OF MENTAL

DISORDERS, Tyrone D. Cannon and Matthew C. Keller 267

SCHIZOTYPAL PERSONALITY: NEURODEVELOPMENTAL AND

PSYCHOSOCIAL TRAJECTORIES, Adrian Raine 291

AUTISM FROM DEVELOPMENTAL AND NEUROPSYCHOLOGICAL

PERSPECTIVES, Marian Sigman, Sarah J. Spence, and A. Ting Wang 327

OBESITY, Anthony N. Fabricatore and Thomas A. Wadden 357

MILD COGNITIVE IMPAIRMENT AND DEMENTIA,Marilyn S. Albert and Deborah Blacker 379

vii

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P1: JRX

February 24, 2006 16:34 Annual Reviews AR271-FM

viii CONTENTS

COGNITION AND AGING IN PSYCHOPATHOLOGY: FOCUS ON

SCHIZOPHRENIA AND DEPRESSION, Philip D. Harvey, AbrahamReichenberg, and Christopher R. Bowie 389

CONTINGENCY MANAGEMENT FOR TREATMENT OF SUBSTANCE

ABUSE, Maxine Stitzer and Nancy Petry 411

PERSONALITY AND RISK OF PHYSICAL ILLNESS, Timothy W. Smith andJustin MacKenzie 435

RECOVERED MEMORIES, Elizabeth F. Loftus and Deborah Davis 469

INDEX

Subject Index 499

ERRATA

An online log of corrections to Annual Review of Clinical Psychology chapters

(if any) may be found at http://www.AnnualReviews.org

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