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Intervention Summary

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Behavioral Day Treatment and Contingency Managed Housing and Work Therapy

Behavioral Day Treatment and Contingency Managed Housing and Work Therapy is a manualized program for adults who are homeless and have co-occurring substance use and nonpsychotic mental disorders. The program, which is based on therapeutic goals management, helps participants to stop using substances and provides them with housing and work training. Program participation is contingent on drug and alcohol abstinence, and participants' use of substances is monitored throughout the 6-month program.

In months 1-2, participants receive Behavioral Day Treatment on weekdays and are provided with lunch and transportation to and from their current housing (e.g., shelter, apartment). Behavioral Day Treatment includes a psychological evaluation, individual counseling, 12-step sessions, relapse prevention training, process groups, AIDS education sessions, assertiveness training, role-playing, participant-governed meetings, weekend planning, and relaxation techniques. Each participant works with a therapist to develop short- and long-term goals in five areas--substance abuse, homelessness, unemployment, lack of non-drug-related social and recreational activities, and emotional and psychiatric problems--and to define outcomes related to the goals. Each participant's attainment of goals is rated in a weekly review, and accomplishments are rewarded with monetary vouchers that participants can use to purchase social and recreational items and activities. As part of the Contingency Managed Housing component, participants also develop employment and housing goals with trained vocational rehabilitation therapists and housing specialists. Urine samples are collected from participants two or three times weekly and tested for drugs and alcohol. After four consecutive negative urine samples (2 weeks of substance abstinence), participants are moved to a rent-free, furnished unit in an apartment complex or a group house. If a participant has a positive urine sample, he or she is removed from the program-provided housing and transported to a shelter. After two consecutive negative urine samples, the participant is moved back to the program-provided housing unit.

In months 3-6, participants receive aftercare through 90-minute group counseling sessions held once weekly. Participants undergo urine testing for drugs and alcohol on the day of the session and then once or twice at random during the week. Aftercare continues to use the goals and psychoeducational content from Behavioral Day Treatment, and individual counseling may be provided in addition to the group sessions. A vocational rehabilitation therapist assesses participants' work skills and interests, and those with continued negative urine samples are referred to a local company contracted by the program to provide work-based training in, for example, painting, drywall work, plumbing, electrical work, or landscaping (Contingency Managed Work Therapy component). Participants work 5.5 hours each weekday and are paid minimum wage. During this time, they can continue to live in the program-provided housing for a reduced rent; however, no participant is removed from housing for not paying rent, only for having a positive urine sample. A positive sample also results in suspension from work until the participant has two consecutive negative samples, after which he or she is able to return to work.

In two of the studies reviewed for this summary, participants also received 6 or 12 months of posttreatment follow-up, which consisted of continuing aftercare group meetings.

Descriptive Information

Areas of Interest Co-occurring disorders
Outcomes Review Date: April 2012
1: Drug and alcohol abstinence
2: Homelessness
Outcome Categories Alcohol
Drugs
Homelessness
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
White
Settings Outpatient
Home
Workplace
Other community settings
Geographic Locations Urban
Suburban
Implementation History Behavioral Day Treatment and Contingency Managed Housing and Work Therapy was originally developed in 1991, and more than 1,000 participants have been served by the program. Over the past two decades, four randomized clinical trials (sponsored by the National Institute on Drug Abuse) and a comparative effectiveness research project (sponsored by SAMHSA) have been conducted in Birmingham, Alabama. In addition, the program has been replicated in Houston, Texas.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: April 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Milby, J. B., Schumacher, J. E., McNamara, C., Wallace, D., Usdan, S., McGill, T., et al. (2000). Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug and Alcohol Dependence, 60(1), 55-67.  Pub Med icon

Milby, J. B., Schumacher, J. E., Wallace, D., Frison, S., McNamara, C., Usdan, S., et al. (2003). Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. Journal of Consulting and Clinical Psychology, 71(3), 619-621.  Pub Med icon

Study 2

Milby, J. B., Schumacher, J. E., Wallace, D., Freedman, M. J., & Vuchinich, R. E. (2005). To house or not to house: The effects of providing housing to homeless substance abusers in treatment. American Journal of Public Health, 95(7), 1259-1265.  Pub Med icon

Study 3

Milby, J. B., Schumacher, J. E., Vuchinich, R. E., Freedman, M. J., Kertesz, S., & Wallace, D. (2008). Toward cost-effective initial care for substance-abusing homeless. Journal of Substance Abuse Treatment, 34(2), 180-191.  Pub Med icon

Supplementary Materials

Drake, R. E., McHugo, G. J., & Biesanz, J. C. (1995). The test-retest reliability of standardized instruments among homeless persons with substance use disorders. Journal of Studies on Alcohol, 56(2), 161-167.   Pub Med icon

Milby, J. B., & Schumacher, J. E. (2011). Quality assurance protocol. Unpublished manuscript.

Milby, J. B., Wallace, D., Ward, C. L., Schumacher, J. E., & Michael, M. (2005). Towards a more sensitive assessment of homelessness: The Homelessness Severity Scale. Journal of Social Distress and Homeless, 14(3&4), 151-169.

Schumacher, J. E., Milby, J. B., Wallace, D., Meehan, D.-C., Kertesz, S., Vuchinich, R., et al. (2007). Meta-analysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990-2006). Journal of Consulting and Clinical Psychology, 75(5), 823-828.  Pub Med icon

Schumacher, J. E., Milby, J. B., Wallace, D., Simpson, C., Frison, S., McNamara, C., et al. (2003). Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons. Experimental and Clinical Psychopharmacology, 11(2), 146-157.  Pub Med icon

Outcomes

Outcome 1: Drug and alcohol abstinence
Description of Measures Drug and alcohol abstinence was measured with urinalysis, and participants' urine samples were tested for cocaine, marijuana, and alcohol. Two studies also tested urine samples for amphetamines, morphine, and benzodiazepines. If a participant admitted to using any other drugs at baseline, then all of the participant's subsequent urine samples were tested for those drugs as well.

All studies included the following measures of abstinence, which were constructed from participants' urine samples that tested negative for drugs and alcohol:

  • Percentage of participants in each condition who had all negative urine samples for the week
  • Longest period of consecutive negative urine samples (measured in weeks) achieved by each participant
In addition to these measures, one study also included the percentage of negative urine samples for each participant in the prior 60 days, and another study included the percentage of negative urine samples for each participant across a treatment timeframe.

If a participant failed to provide a urine sample for drug and alcohol testing, he or she was categorized as having a positive result--unless the participant was excused from that test for a valid reason (e.g., medical or social service appointment, illness).
Key Findings In a 6-month randomized clinical trial (RCT), participants who were homeless and met DSM-III-R criteria for co-occurring cocaine abuse or dependence and nonpsychotic mental disorders were assigned to one of two treatment conditions: the intervention group, which received 2 months of Behavioral Day Treatment and Contingency Managed Housing followed by 4 months of weekly aftercare group meetings and Contingency Managed Housing and Work Therapy, or the comparison group, which received 2 months of Behavioral Day Treatment followed by 4 months of weekly aftercare group meetings. Urine samples were collected from participants twice weekly at random during months 1-2 of the study (excluding weekends and not on consecutive days). During months 3-6 of the study, urine samples were collected twice weekly: once during the regularly scheduled aftercare meeting and once on a random day (but not on consecutive days). Positive urine samples disputed by the participant were subjected to confirmation testing. To remain in housing and work in months 3-6, participants in the intervention group had to maintain negative urine samples (i.e., abstain from drug and alcohol use). Assessments occurred at baseline, at the end of Behavioral Day Treatment (2 months after baseline), and at the end of the study (6 months after baseline). Findings included the following:

  • The percentage of days of abstinence from drug and alcohol use in the prior 60 days was higher for the intervention group than the comparison group at 2 months after baseline (71% vs. 41%; p < .0001) and at 6 months after baseline (41% vs. 15%; p = .0009).
  • The average weekly percentage of participants who were abstinent from drug and alcohol use was higher for the intervention group than the comparison group across months 1-2 (69% vs. 42%; p < .0001) and across months 3-6 (54% vs. 18%; p = .007).
  • At 2 months after baseline, the average number of consecutive weeks of abstinence from drug and alcohol use was higher for the intervention group than the comparison group (4.87 weeks vs. 2.84 weeks; p = .0004). This group difference was associated with a medium effect size (Cohen's d = 0.74).
  • At 6 months after baseline, the average number of consecutive weeks of abstinence from drug and alcohol use was higher for the intervention group than the comparison group (9.51 weeks vs. 3.88 weeks; p = .0001). This group difference was associated with a large effect size (Cohen's d = 1.06).
  • From 2 to 6 months after baseline, participants in the intervention group had a greater increase in consecutive weeks of abstinence from drug and alcohol use relative to participants in the comparison group (4.87 to 9.51 weeks vs. 2.84 to 3.88 weeks; p = .0001).
A 12-month RCT was conducted with participants who were homeless and met DSM-III-R criteria for co-occurring cocaine abuse and dependence and nonpsychotic mental disorders. During the 6-month treatment period, all participants received Behavioral Day Treatment (months 1-2) and weekly aftercare group meetings and non-abstinence-contingent work therapy (months 4-6); participants also received posttreatment follow-up, which consisted of continuing weekly aftercare group meetings (months 7-12). Urine samples from all participants were randomly collected and tested for drug and alcohol use twice weekly during months 1-6 and once weekly during months 7-12. If a test result was inconclusive, the original urine sample was retested once or twice, and the two most consistent results were used to determine the data point. Participants were assigned to one of three housing conditions:

  • The Contingency Managed Housing group, which received rent-free housing in months 1-2 after two consecutive negative urine samples, followed by low-rent housing in months 3-6. Participants paid monthly rent with money earned through non-abstinence-contingent work therapy or other employment. If units were still available, participants could continue in the low-rent housing in months 7-12. To remain in housing in months 1-6, participants in this group had to maintain negative urine samples (i.e., abstain from drug and alcohol use); however, during months 7-12, housing was no longer contingent on the participants maintaining negative urine samples.
  • The non-abstinence-contingent housing group, which received rent-free housing in months 1-2 after submitting two urine samples, followed by low-rent housing in months 3-6 with an option to continue in the low-rent housing in months 7-12. Participants paid monthly rent with money earned through non-abstinence-contingent work therapy or other employment. If units were still available, participants could continue in the low-rent housing in months 7-12.
  • The no-housing group, which remained in shelters or other temporary housing throughout the 12-month study.
Assessments occurred at baseline, at the end of Behavioral Day Treatment (2 months after baseline), at the end of treatment (6 months after baseline), and at the end of the 6-month posttreatment follow-up (12 months after baseline). Findings included the following:

  • Across months 1-2, the average weekly percentage of participants who were abstinent from drug and alcohol use was higher for both housing groups than the no-housing group (69% of the Contingency Managed Housing group and 60% of the non-abstinence-contingent housing group vs. 41% of the no-housing group; p < .0001). Also across months 1-2, the average weekly percentage of participants who were abstinent from drug and alcohol use was higher for each of the housing groups than the no-housing group: 69% of the Contingency Managed Housing group vs. 41% of the no-housing group (p < .0001) and 60% of the non-abstinence-contingent housing group vs. 41% of the no-housing group (p = .0015). However, no significant difference in the average weekly percentage of participants who were abstinent was found between the two housed groups across months 1-2.
  • Across months 3-6, the average weekly percentage of participants who were abstinent from drug and alcohol use was higher for both housing groups than the no-housing group (46% of the Contingency Managed Housing group and 40% of the non-abstinence-contingent housing group vs. 18% of the no-housing group; p = .0001). Also across months 3-6, the average weekly percentage of participants who were abstinent from drug and alcohol use was higher for each of the housing groups than the no-housing group: 46% of the Contingency Managed Housing group vs. 18% of the no-housing group (p < .0001) and 40% of the non-abstinence-contingent housing group vs. 18% of the no-housing group (p = .0003). Although the average weekly percentage of participants who were abstinent was higher for the Contingency Managed Housing group than the non-abstinence-contingent housing group (46% vs. 40%), this finding was not significant.
  • Across months 1-6, the average number of consecutive weeks of abstinence from drug and alcohol use was higher for the Contingency Managed Housing group than the no-housing group (8.32 weeks vs. 4.48 weeks; p = .0004). Although the average number of consecutive weeks of abstinence was higher for the non-abstinence-contingent housing group than the no-housing group (6.60 weeks vs. 4.48 weeks), this finding was not significant. In addition, although the average number of consecutive weeks of abstinence was higher for the Contingency Managed Housing group than the non-abstinence-contingent housing group (8.32 weeks vs. 6.60 weeks), this finding also was not significant.
An 18-month RCT was conducted with participants who were homeless and met DSM-IV criteria for co-occurring cocaine abuse and dependence and nonpsychotic mental disorders. Participants were assigned to one of two treatment conditions:

  • The intervention group, which received Behavioral Day Treatment and Contingency Managed Housing and Work Therapy (months 1-6), which required participants to maintain negative urine samples (i.e., abstain from drug and alcohol use).
  • The comparison group, which did not receive Behavioral Day Treatment but did receive Contingency Managed Housing and Work Therapy (months 1-6), which required participants to maintain negative urine samples (i.e., abstain from drug and alcohol use).
All participants received posttreatment follow-up, which consisted of continuing weekly aftercare group meetings during months 7-12 and recommended aftercare group meetings during months 13-18. Starting in month 7, participants had the opportunity to transfer to federally funded Shelter Plus Care housing, which provided low-rent housing on a space-available basis. Although the aftercare and posttreatment follow-up services were not contingent on participants maintaining negative urine samples, a missed or positive sample could result in the participant's removal from the Shelter Plus Care housing or placement at the bottom of the waiting list. Urine samples were collected at baseline, three times weekly (Monday, Wednesday, and Friday) during months 1-6, randomly once every week during months 7-12, and randomly once every 2 months during months 13-18. Findings included the following:

  • The average percentage of participants who were abstinent from drug and alcohol use was higher for the intervention group than the comparison group across months 7-12 (49% vs. 34%; p < .005) and across months 13-18 (40% vs. 27%; p < .014). However, no significant difference in the average percentage of participants who were abstinent was found between the groups across months 1-6.
  • Across months 1-12, the average number of consecutive weeks of abstinence from drug and alcohol use was higher for the intervention group than the comparison group (19.2 weeks vs. 13.9 weeks; p = .009).
Studies Measuring Outcome Study 1, Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Homelessness
Description of Measures Homelessness was measured using a section of the Retrospective Interview for Housing, Employment, and Treatment History (RHETRO), which was adapted from the recent housing history section of the Personal History Form used by the Columbia University Center for Homelessness Prevention Studies. Participants were asked to provide the number of days they spent in the following four housing domains during the past 60 days:

  • Literal homeless situations (i.e., indoor public place, subway or bus, abandoned building, car or other private vehicle, outdoor place, emergency shelter)
  • Marginal homeless situations (i.e., hotel/motel, someone else's room, someone else's apartment or house, transitional housing)
  • Institutional housing (i.e., long-term alcohol- and drug-free facility, hospital, nursing home, treatment or recovery program, jail or prison, corrections halfway house)
  • Stable housing (i.e., own apartment or house, parent's/guardian's apartment or house, group home, boarding house or board-and-care facility, own room in someone else's home or apartment)
The percentage of days in stable housing in the past 60 days was calculated by dividing the total number of days in stable housing by 60 days (i.e., the sum of days in stable housing, days in institutional housing, and days homeless, including literal and marginal homeless situations).
Key Findings In a 6-month RCT, participants who were homeless and met DSM-III-R criteria for co-occurring cocaine abuse or dependence and nonpsychotic mental disorders were assigned to one of two treatment conditions: the intervention group, which received 2 months of Behavioral Day Treatment and Contingency Managed Housing followed by 4 months of weekly aftercare group meetings and Contingency Managed Housing and Work Therapy, or the comparison group, which received 2 months of Behavioral Day Treatment followed by 4 months of weekly aftercare group meetings. Assessments occurred at baseline, at the end of Behavioral Day Treatment (2 months after baseline), and at the end of the study (6 months after baseline). At 6 months after baseline, the percentage of days in stable housing in the past 60 days was higher for the intervention group than the comparison group (59% vs. 4%; p = .016).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 76.4% Male
23.6% Female
82.7% Black or African American
17.3% White
Study 2 26-55 (Adult) 75.4% Male
24.6% Female
90.8% Black or African American
9.2% White
Study 3 26-55 (Adult) 72.8% Male
27.2% Female
94.2% Black or African American
5.8% White

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Drug and alcohol abstinence 3.2 2.9 3.2 2.3 2.6 3.5 2.9
2: Homelessness 2.8 2.7 3.2 2.5 2.1 3.5 2.8

Study Strengths

The urine testing used in all three studies is an objective index of drug abstinence and has a long history of use in forensic settings; it has strong reliability and validity, with procedural checks that add to the validity of the test results. In all three studies, the use of several different, but convergent, abstinence measures added to the validity. In one study, evidence of criterion validity was provided for two of the abstinence measures derived from urine test data for participants with a global diagnosis of psychoactive substance use disorder by DSM-III-R criteria: longest period of consecutive negative urine samples (measured in weeks) achieved by each participant, and percentage of negative urine samples for each participant in the prior 60 days. In one study, homelessness was measured by self-report using a slightly modified interview (RHETRO) from a standardized assessment instrument (Personal History Form) that was previously used in multisite studies of homeless populations and had good overall reliability and face validity. Research assistants collecting the assessment data were blind to the treatment conditions, and intervention fidelity was supported by the use of highly structured manuals and a fidelity instrument (Behavior Criteria Observation Checklist), which were used by trained clinicians to rate intervention sessions at random on a quarterly basis for immediate corrective action and retraining of therapists if needed. The studies were randomized, longitudinal, and well designed to systematically test different components of a theory-based, multisystemic intervention with abstinence-contingent incentives. Random assignment in all three studies controlled for many confounds, and multiple statistical analyses were performed for remaining confounds to determine their impact on outcomes. All three studies used an intent-to-treat approach with appropriate statistical modeling of longitudinal data by generalized and mixed linear models.

Study Weaknesses

The use of infrequent and slightly different random sampling protocols for urinalysis across time periods within each study and across related studies measuring the same outcome introduces a degree of error and reduces the measure's reliability (stability) in determining sustained drug abstinence. No sample test-retest or interrater reliability was presented for the RHETRO, and no independent or collateral verification of validity was presented for its use with a population with a co-occurring disorder diagnosis (including high psychiatric severity). In regard to urine testing, there was a moderate to high amount of missing data, varying by treatment group across time periods in all three studies. The statistical approach to incorporating varying levels of missing data into the analyses was limited to simple imputation, and there was no correction in the experimentwise alpha level for significant differences between groups as recommended for the numerous statistical comparisons performed in each of the three studies.

Readiness for Dissemination
Review Date: April 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Milby, J., & Schumacher, J. (2011). Behavioral Day Treatment manual. University of Alabama at Birmingham.

Milby, J., & Schumacher, J. (2011). Contingency Managed Housing manual. University of Alabama at Birmingham.

Milby, J., & Schumacher, J. (2011). Contingency Managed Work Therapy manual. University of Alabama at Birmingham.

Milby, J., & Schumacher, J. (2011). Standard operating procedures manual. University of Alabama at Birmingham.

Schumacher, J., & Milby, J. (2005). HIV prevention program. University of Alabama at Birmingham.

Schumacher, J., & Milby, J. (2011). TGM: Therapeutic goals management manual. University of Alabama at Birmingham.

Therapeutic goals management online course, http://chab-lms.jbsinternational.com/

Other dissemination materials:

  • Community resource assessment
  • Program description
  • Quality assurance protocol
  • Training description
  • Treatment fidelity rating sheets

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 3.8 3.5 3.6

Dissemination Strengths

Five highly detailed manuals illustrate the program's objectives, strategies, and components and provide supplemental materials and forms. An outline of the community resources needed for program implementation is provided. The program developers customize on- and off-site training and support options to meet the needs and resources of individual implementation sites. The online therapeutic goals management course is clearly presented and detailed; it strengthens implementation fidelity with scripts and specific examples of the program. Numerous fidelity checklists, recommended outcome measures, and a protocol for the delivery of these measures are provided to support quality assurance.

Dissemination Weaknesses

Program materials lack specific information regarding the complex interrelationship and overlap of components and how they work as an integrated program. The manuals contain information relating to the initial development site, which may not be applicable to other implementation sites. Little guidance is provided on how the quality assurance documents are integrated to support implementation fidelity and evaluate program outcomes.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Behavioral Day Treatment Manual Free Yes
Contingency Managed Housing Manual Free Yes
Contingency Managed Work Therapy Manual Free Yes
Therapeutic Goals Management Manual Free Yes
Standard Operating Procedures Manual Free Yes
1- to 3-day, on-site training $1,800 per day for up to 10 participants, plus travel expenses Yes
Off-site comprehensive or specialized training and active site observation in Birmingham, AL $1,200 per day for up to 5 participants Yes
Therapeutic Goals Management (online course) Free Yes
On-site technical assistance and consultation $1,200 per day, plus travel expenses No
Brief phone-based technical assistance and consultation Free No
Behavioral criteria observational checklists Free Yes
Contact Information

To learn more about implementation, contact:
Joseph E. Schumacher, Ph.D.
(205) 529-8250
jschumacher@uabmc.edu

To learn more about research, contact:
Jesse B. Milby, Ph.D., ABPP
(205) 934-8723
jmilby@uab.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.