Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

204 III. SUBSTANCES OF ABUSEexperienced. Despite the strong extinction of arousal, these effects diminishedover time, unless they were reinforced with repeated cue exposure sessions.Voucher-based reinforcement strategies have also shown considerablepromise (Higgins, Budney, Bickel, & Foerg, 1994; Higgins et al., 1995, 2000).Higgins and colleagues (1994) demonstrated that voucher incentives (in combinationwith comprehensive behavioral intervention) enhanced retention inthe 24-week-long treatment program both for patients receiving interventions(75%) and those receiving behavioral therapy only (40%). In addition, those inthe voucher group had greater continuous abstinence and evidenced greaterimprovements on the Addiction Severity Index (ASI) Drug and Psychiatricscales than those not receiving vouchers. Subsequent follow-up assessmentsindicated that these gains were maintained 6 months after treatment (Higginset al., 1995), and as much as 15 months after treatment (Higgins et al., 2000).Other studies of contingent vouchers have yielded similarly positive outcomesin cocaine-dependent outpatients (Kirby, Marlowe, Festinger, Lamb, & Platt,1998; Silverman et al., 1996). In addition, a study by Rawson and colleagues(2002) compared contingency management (vouchers), CBT, a combinationof the two, and a “no-cocaine-treatment condition,” which consisted of methadonemaintenance for heroin addiction only in patients with heroin andcocaine dependence. They found that contingency management was associatedwith significantly higher levels of cocaine abstinence than were the CBT orcontrol interventions. However, the CBT group showed improvement at the 6-and 12-month follow-up points that was congruent with the contingency managementgroup.Unfortunately, not all substance abusers are motivated to change theirdrug use behavior; this is particularly true of patients with comorbid psychiatricdisorders, who may be overwhelmed by their multiple problems and prior treatmentfailures (Martino, McCance-Katz, Workman, & Boozang, 1995; Ziedonis& Fischer, 1996). Motivational enhancement therapy (MET), or motivationalinterviewing (MI), a nonconfrontational approach developed by Miller andRollnick (1991), was originally designed for working with problem drinkers. Innumerous trials, the principles of MI have been shown to be effective, sometimesafter only one or two sessions (Bien, Miker, & Tonigan, 1993; Brown &Miller, 1993). Because of promising results with alcoholics, MET/MI is currentlybeing adapted for use with drug abusers, including those with cocainedependence and psychiatric comorbidity. MET/MI works in tandem with thestages-of-change model of Prochaska, DiClemente, and Norcross (1992). Themodel postulates five distinct stages: precontemplation, contemplation, action,maintenance, and relapse. These stages can be assessed via paper-and-pencilinstruments, such as the University of Rhode Island Change Assessment(URICA). Different therapeutic strategies are employed, based on the patient’sdesignated stage of change. MET/MI represents a clear departure from traditionaldrug abuse counseling strategies. Because acceptance of the addict iden-