and services have been most clearly associated with improved personal health and social function following treatment but not as well related to reduced alcohol and drug use. In addition, and not surprisingly, these treatments have only been shown to be effective with those patients having more severe problems in the target area (matching effect)—that is, if there has been no indication of a relatively severe problem in the target area, there has typically been no evidence that the provision of the target therapy is effective or worthwhile (see Woody et al., 1984). One exception to this appears to be behavioral marital or couples therapy, which has typically demonstrated a "main effect" for all couples in the studies. This might be because most marriages in which one or both partners are actively abusing alcohol or drugs could be characterized by fairly severe marital problems. However, even in the case of marital therapy, some matching effects have been found. One study found that the effectiveness of couples therapy for alcoholics varied as a function of complex interactions involving the patient's degree of investment in relationships, degree of support for abstinence from significant others, and planned number of conjoint sessions (Longabaugh et al., 1995).
Community Reinforcement and Contingency Contracting—Azrin and colleagues initially developed the "Community Reinforcement Approach" (CRA) and tested it against other "standard" treatment interventions (Azrin et al., 1982). CRA includes conjoint therapy, job finding training, counseling focused on alcohol-free social and recreational activities, monitored disulfiram, and an alcohol-free social club. The goal of CRA is to make abstinence more rewarding than continued use (Meyers and Smith, 1995). In a study in which patients were randomly assigned to CRA or to a standard hospital treatment program, those getting CRA drank less, spent fewer days away from home, worked more days, and were institutionalized less over a 24-month follow-up (Azrin et al., 1982).
A more recent set of studies by Higgins et al. (Higgins et al., 1991, 1993, 1994, 1995) has used the CRA approach with cocaine dependent patients. Here, cocaine dependent patients seeking outpatient treatment were randomly assigned to receive either standard drug counseling and referral to AA, or a multicomponent behavioral treatment integrating contingency managed counseling, community-based incentives, and family therapy comparable to the CRA model (Higgins et al., 1991). The CRA model retained more patients in treatment, produced more abstinent patients and longer periods of abstinence, and produced greater improvements in personal function than the standard counseling approach. Following the overall findings, this group of investigators systematically "disassembled" the CRA model and examined the individual "ingredients" of family therapy (Higgins et al., 1993), incentives (Higgins et al., 1994),