ATM was well received, in that a substantial proportion of people assigned to this voluntary intervention attended money management sessions, stored their checkbooks or bank cards with the money manager, and contracted to receive more of their funds when they achieved individually chosen goals. Despite a ceiling effect caused by the overall high levels of abstinence among veterans who were followed, ATM showed promise as a treatment.
ATM was not associated with significant benefit, as shown by a group-by-time interaction, on self-reported abstinence or on cocaine-negative urine toxicology tests, but the intervention was associated with significant reductions in the ASI alcohol and drug abuse composite scores. Unlike dichotomous measures of abstinence or use, ASI composite scores are continuous measures reflecting other factors, such as the extent of drug-related problems and how much treatment is needed. One possible explanation for the effect on the drug and alcohol use composite scores and lack of significant effects on self-report and toxicology is that ATM may mitigate the severity of substance-related problems without reducing the proportion of weeks of substance use. It is noteworthy that the patterns of group-by-time effects concerning cocaine use all were in the direction of efficacy of the ATM intervention. In addition to the significant effect on drug use composite scores among participants assigned to ATM, there were statistically nonsignificant trends toward less self-reported cocaine use, fewer positive urine toxicology tests, and less money spent on substances of abuse.
A money management intervention was unacceptable to many potential participants, as suggested by the fact that only 41% of eligible participants proceeded to the random assignment portion of the trial, but it was impressive that participation in ATM was extensive after randomization and that subjective ratings of ATM were quite favorable. These results are consistent with those of other studies in which participants in a community-based payee program indicated that although enrollment was involuntary, patients found money management helpful over time (27
). Participation in ATM also reflected the fact that the participants wanted help with their finances. The desire for help with finances was also reflected in the surprisingly high participation in a control condition that offered little counselor input beyond support for completing a budgeting workbook. People with little income and people who have serious mental illness indicate a desire for help with concrete financial concerns (28
), and the satisfaction of material needs typically takes precedence over other needs (29
The tested version of advisor-teller money management involved storing checkbooks and bank cards instead of a version of ATM more akin to representative payee practice, in which the money manager receives the patient’s funds and stores them in an account that can be accessed only by the payee. Although most veterans assigned to ATM agreed to have their savings materials stored and to meet a money manager to budget, few participants (five out of 44 ATM participants) allowed the money manager to delay unplanned spending to reconsider the unplanned expenditure. It is possible that the intervention’s effects would be greater if the budgeting and training components of ATM were used in conjunction with the restrictions on beneficiary access to funds implemented by assigned representative payees.
Limitations of this study include the restriction to veterans, almost all of whom were male, and high abstinence rates in both groups. Several factors mitigated against finding a robust effect of ATM in this population. The high rates of abstinence among study participants created a control group ceiling effect that was hard to improve on. This ceiling effect did not appear to be caused by selective dropout of participants with more severe baseline addiction, because post hoc analyses showed no association between baseline addiction severity measures and percentage of follow-up interviews that were completed. Further evidence that selective attrition did not account for the high abstinence rates comes from another study of patients with psychiatric disorders and concomitant substance abuse, conducted at the same sites and during the same period as our study, which also reported extremely high abstinence rates (30
). Our randomly assigned sample of 85 had sufficient power to detect an effect size of .4 with power of .8 and significance of .05, two-tailed (31
), but enrollment of people who used alcohol alone also may have diluted the study’s power to detect an effect of ATM on cocaine use. Although the “check effect” of more substance use when checks are received at the beginning of the month has been demonstrated for both alcohol and other drug use (6
), approaches based on money management may be more effective for cocaine because cocaine binges are more expensive.
In summary, this study found that a money management–based treatment targeting cocaine and alcohol use is feasible, acceptable to participants, and potentially efficacious.