These results are encouraging in a number of ways. First, the enhanced incentives condition was effective at increasing the likelihood of meeting intermediate goals needed for treatment success, including achieving a more rapid and intense job search and minimizing substance abuse relapse. According to Vinokur and Schul (2002)
, these intermediate factors are the most predictive of a successful transition to competitive employment and are typically not a central focus of VR programs. The higher scores on the Job Search Behaviors Scale at Week 16 for the enhanced incentives group suggests activation of a broader array of job-search activities. It is noteworthy that 5 of 8 participants in the CWT-only group had lower scores on the Job Search Behaviors Scale 4 months after entry in CWT relative to their scores at the time of entry (see ). In contrast, 2 of 10 participants in the enhanced incentives condition had lower scores and 6 of 10 had higher scores. This provides some suggestion that the payments for job-search activities had effects well after they were available, whereas paid activities in CWT only may function as a disincentive to search for jobs for some participants.
Results for Individual Participants
Also consistent is the finding that the payments were related to significant differences in sustained drug and alcohol abstinence. Drebing et al. (2000)
have noted that substance abuse relapse is one of the most common causes of dropout and treatment failure in VR. Although the payments did appear to influence drug and alcohol abstinence, there is less evidence that lapses in drug and alcohol abstinence were directly tied to dropout or discharge from CWT (see ). Examination of individual cases makes it clear that participants who relapsed but who continued to attend CWT were either not identified by CWT staff as having relapsed or were not discharged if the relapse was brief and they agreed to seek additional treatment. Participants who relapsed and then left their residences or did not attend CWT were more promptly discharged. Four participants who relapsed and were not discharged were still able to transition to competitive jobs.
Because access to money is widely recognized as a trigger of relapse, we were concerned that the payments would lead to substance abuse. This does not seem to have been the case. The incentive regimen did contain a partial stopgap against relapse in that money could not be earned following recent drug use.
With respect to the intensity of participation in CWT, the results are somewhat mixed. Those with the payments worked more, earned more, and were somewhat less likely to have dropped out by Week 16, although dropout rates for both groups were fairly similar. A range of studies in substance abuse treatment settings have shown enhanced compliance secondary to payments that directly or indirectly reward participation and retention. It is possible that dropout in substance abuse programs is more closely tied to relapse, so payments for abstinence have a greater impact on dropout rates. It is also possible that the failure to note differences in retention may be due to the impact of noncontingent payment for the CWT-only condition. With respect to the intensity of participation, we were concerned that a cash payment program might reduce the likelihood of transitioning to competitive work by reducing the need for cash. That was not found to be the case, in that the average wage earnings for those in the enhanced incentives group was $1,900 more than the wages of those in the CWT-only group. Instead of reducing earned income, the payments spurred further earnings.
With respect to outcome, the enhanced incentives group had an earlier transition to competitive employment and a greater number of days of employment, but the differences were not statistically significant. The difference between the two groups diminished between Weeks 12 and 16, although gains continued to accrue in both groups. It is possible that the payments encouraged a more rapid transition for those who would eventually move to a competitive job without the payments. It is noteworthy that of all the job-related payments, those for getting a competitive job were the least likely to be earned. This is due in part to the fact that they were contingent on the other rewarded behaviors (e.g., creating a resume and going on a job interview). In general, obtaining a job is also more difficult in terms of total amount of effort and the potential risk of failure, so participants' ambivalence about obtaining a job is likely to be greater than their ambivalence about job-search tasks. Results from other contingency management studies suggest that, in principle, extending the time for which payments are available or increasing the amount of the payment for obtaining a job would be likely to further increase the number of participants in competitive jobs (Petry, 2000
; Petry et al., 2001
). It should also be noted that in trying to keep the payments for abstinence similar to the published guidelines, we designed the payments with an imbalance in the total payments available favoring abstinence ($736) over obtaining and maintaining work ($270). In retrospect, for a study of VR, this may have been a mistake. In our subsequent work, we have shifted the balance in favor of work payments.
Overall, these findings are promising. There appears to be a natural synergy between VR programs like CWT and contingency management techniques, in that each addresses the other's limitations. CWT is often undermined by misuse of drugs and alcohol and by participants' concerns about transitioning to competitive employment, but it has the advantage of providing long-term reinforcement in the form of both earnings and less tangible rewards such as social status and self-esteem. Contingency management techniques can enhance the ability to meet treatment goals such as retention or abstinence, but can result in a decline in effects when the contrived reinforcers are removed. By combining VR and contingency management, both short- and long-term outcomes in VR participants may be enhanced. VR programs also appear to be a more natural setting for contingency management than other clinical programs. Petry (2000)
notes that “despite compelling evidence regarding their efficacy and the wide acceptability and applicability of these procedures, contingency management approaches are rarely implemented in [substance abuse] treatment programs” (p. 9). This appears to reflect distaste for the artificiality of paying clients for meeting clinical goals, discomfort with working with money, and concern about the impact of contingency payments on total program cost. These factors are less relevant to VR settings. Financial payments are already used in VR, including pay for work as well as bonuses for meeting goals. In a recent national survey of CWT programs, 18% were already offering some form of cash bonus to participants who were participating constructively (Drebing, Rosenheck, & Penk, 2001
). Restructuring the existing financial payments to include explicit links to clinical goals is a relatively small step for VR programs. Second, the infrastructure needed to support payment programs is already in place in CWT programs, and resources in the form of the Special Therapeutic and Rehabilitation Activities Fund can easily be set aside from current contracts.
This initial study suggests that enhanced payments could improve outcomes for VR programs. It is important to remain cautious in our conclusions. First, this is a relatively small study that needs replication with a larger sample. A replication is under way. Second, the brief follow-up period limits the conclusions that can be drawn. With respect to competitive employment, differences in the two groups diminished toward the end of the 16 weeks. A longer follow-up may show that the payments result in a quicker move to work but that both conditions actually result in similar numbers of participants moving to work. It is possible that by encouraging a more rapid job search, the payments result in participants transitioning to competitive jobs before they are ready to maintain those jobs. Additional data are needed to document that a more intensive job search and an earlier transition to competitive employment do not result in shorter job tenure or any other unintended negative outcomes. The withdrawal of 2 participants after assignment to the enhanced incentives condition raises the question of whether, despite their self-reports, assignment to this condition encouraged them to withdraw. This has not been noted as a problem in prior contingency management studies, but it is worth monitoring carefully in future efforts, particularly given this new application to a VR setting. Four participants in the CWT-only condition had missing urine-screen data resulting in positive results, compared to none in the enhanced incentives condition. The assumption that missing data should be treated as evidence of substance abuse may be inaccurate and may inflate the relapse rate among the CWT-only group. Similarly, the lack of observed urine screens may add error to the substance use data, because incentives for clean urine screens may have motivated some to substitute clean urine for a true sample. Finally, a major concern about this type of intervention is the cost. An additional cost of $1,000 in payments would almost double the cost of care per CWT participant (Blow et al., 2001
). Further study is needed to determine (a) the relation between the total cost of payments and outcome, (b) whether the payments result in secondary costs or savings in terms of changes in use of other health services, and (c) whether it is feasible and effective to fund payments out of employer contracts.
In summary, this study demonstrates that the addition of a contingency management intervention to a VR program can have a positive impact on program compliance and outcome in dually diagnosed participants. Further study is needed to address questions regarding the amount and structure of the reinforcement schedule, the additional benefit derived from payments for drug and alcohol abstinence relative to the impact of the work-related payments, and the long-term impact of payments on job attainment and tenure.