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Community Reinforcement + Vouchers Approach (CRA + Vouchers)

Topic Areas
Scientific Rating
Child Welfare Relevance
Substance Abuse Treatment (Adult)
2  — Supported by Research Evidence
Medium

About This Program

Target Population: Adults age 18 or older with a diagnosis of cocaine abuse or dependence

Program Overview

CRA + Vouchers has two main components. The Community Reinforcement Approach (CRA) component is an intensive psychosocial therapy emphasizing changes in substance use; vocation; social and recreational practices; and coping skills. The Voucher Approach is a contingency- management intervention where clients earn material incentives for remaining in treatment and sustaining cocaine abstinence verified by urine toxicology testing.

Program Goals

The program representative did not provide information about the program’s goals.

Logic Model

The program representative did not provide information about a Logic Model for Community Reinforcement + Vouchers Approach (CRA + Vouchers).

Essential Components

The essential components of Community Reinforcement + Vouchers Approach (CRA + Vouchers) include:

  • The Voucher Program
    • The voucher program is a contingency-management procedure that systematically reinforces treatment retention and cocaine abstinence, the primary targets of CRA + Vouchers.
    • Points are awarded for cocaine-negative urine test results, and the number of points is increased for each consecutive negative urine sample.
    • Failure to submit a scheduled specimen is treated as a cocaine positive test.
    • This procedure not only provides a reward for each cocaine-negative test but also provides a greater incentive for patients who maintain long periods of continuous abstinence.
    • This system also recognizes that slips (use of cocaine) are highly probable during treatment. To discourage slips, the value of the voucher reverts to its initial value whenever cocaine use occurs. However, patients can regain the higher voucher values by providing five consecutive cocaine-negative specimens. Points already in the patients' individual accounts can never be lost.
    • Money is not provided directly to patients. Instead, a staff member uses vouchers to purchase retail items in the community. Purchases are only approved if, in the therapists' opinion, they are in concert with individual treatment goals related to increasing drug-free pro-social activities.
  • Counseling Component
    • The treatment plan should target areas for change that are directly related to cocaine use, are likely to decrease cocaine use, or will reduce the probability of relapse.
    • CRA + Vouchers requires both therapists and patients to adopt an active, can-do, make-it-happen attitude throughout treatment.
    • Therapists do whatever it takes to help patients make lifestyle changes. This includes taking patients to appointments or job interviews, initiating recreational activities with them, scheduling sessions at different times to accomplish specific goals, having patients make phone calls while in the office, assisting them with appointments, and searching newspapers for job possibilities or recreational events.

Program Delivery

Adult Services

Community Reinforcement + Vouchers Approach (CRA + Vouchers) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Diagnosis of cocaine abuse or dependence

Recommended Intensity:

Depending on where they are in treatment, clients are seen for therapy between 2 (or more) times a week and once a month and provide urine samples between 3 times a week and once a month.

Recommended Duration:

Therapy session duration depends on the client's needs and the nature of the goals for the particular session. Generally, sessions are 60 minutes. The recommended treatment duration is 24 weeks of treatment and 24 weeks of aftercare. During weeks 1-12 of treatment, clients are asked to visit the clinic to provide urine samples for drug screens three times per week and have individual therapy sessions at least two times a week. During weeks 12-24, the intensity of treatment is decreased to urine toxicology testing twice a week and therapy sessions once a week. After the 24-weeks of treatment, a 24-week period of "aftercare" is recommended, involving at least one check-in session a month, a brief therapy session and a urine toxicology test.

Delivery Setting

This program is typically conducted in a(n):

  • Outpatient Clinic

Homework

Community Reinforcement + Vouchers Approach (CRA + Vouchers) includes a homework component:

A primary goal of the program is behavior and lifestyle change. This is an intensive treatment in which patients need to be extremely active participants. During treatment planning and throughout individual sessions, the therapist and client create between-session goals. The goals are in the areas of developing new and healthier social networks, recreational activities, family relationships, and vocational direction. The first order of business of each session is review of the patient's follow-through on their daily and weekly goals.

Resources Needed to Run Program

The typical resources for implementing the program are:

Staffing needs:

  • Two therapists
  • One program manager
  • One data manager
  • One research assistant
  • One secretary
  • One post-doctoral fellow
  • One supervisory psychologist

Space/room requirements: sufficient to accommodate each of the staff members and to provide sufficient privacy for the patients. It is also necessary to have onsite biochemical verification in order to immediately detect cocaine use.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Therapists need a Master's degree and supervision by a licensed PhD-level Psychologist. Research assistants need to have a Bachelor's degree.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual Details:

Training Information

There is not training available for this program.

Implementation Information

Pre-Implementation Materials

The program representative did not provide information about pre-implementation materials.

Formal Support for Implementation

The program representative did not provide information about formal support for implementation of Community Reinforcement + Vouchers Approach (CRA + Vouchers).

Fidelity Measures

The program representative did not provide information about fidelity measures of Community Reinforcement + Vouchers Approach (CRA + Vouchers).

Implementation Guides or Manuals

The program representative did not provide information about implementation guides or manuals for Community Reinforcement + Vouchers Approach (CRA + Vouchers).

Research on How to Implement the Program

The program representative did not provide information about research conducted on how to implement Community Reinforcement + Vouchers Approach (CRA + Vouchers).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Budney, A. J., Bickel, W. K., & Hughes, J. R. (1991). A behavioral approach to achieving initial cocaine abstinence. The American Journal of Psychiatry, 148(9), 1218–1224. https://doi.org/10.1176/ajp.148.9.1218

Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)
Number of Participants: 28

Population:

  • Age — Intervention: Mean=29.0 years; 12-Step: Mean=30.5 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were individuals entering an outpatient clinic for cocaine dependence.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the efficacy of a behavioral treatment program for achieving initial cocaine abstinence in individuals enrolled in outpatient treatment for cocaine dependence. Participants were assigned to either Community Reinforcement + Vouchers Approach (CRA+V) or to a traditional 12-step approach. Measures utilized include urinalysis. Results indicate that participants in the CRA+V condition maintained abstinence from cocaine longer than those in the 12-step condition. However, there was a significantly higher rate of marijuana use in the behavioral group. Groups did not differ in rates of other drug use during the study period. The CRA+V group also had a greater rate of retention than those in the 12-step condition. Limitations include the small sample size and lack of randomization to groups.

Length of controlled postintervention follow-up: None.

Higgins, S. T., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Badger, G. (1993). Achieving cocaine abstinence with a behavioral approach. The American Journal of Psychiatry, 150(5), 763–769. https://doi.org/10.1176/ajp.150.5.763

Type of Study: Randomized controlled trial
Number of Participants: 38

Population:

  • Age — Intervention: Mean=28.5 years; Counseling: Mean=30.1 years
  • Race/Ethnicity — 100% White
  • Gender — 100% Male
  • Status — Participants were cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare the efficacy of a multicomponent behavioral treatment and drug abuse counseling for cocaine-dependent individuals. Participants were randomly assigned to receive either the Community Reinforcement + Vouchers Approach (CRA+V) program or traditional counseling based on the disease model of dependence and recovery. The counseling condition combined initial individual counseling with later 12-step group attendance. Measures utilized include urinalysis. Results indicate that a significantly greater number of the CRA+V group completed 24 weeks of treatment (58% versus 11%) and a greater proportion had maintained sobriety at 8 and 16 weeks. Limitations include the exclusively Caucasian sample and the lack of any crack cocaine users, which limit generalizability of findings to other populations, as well as the lack of follow-up.

Length of controlled postintervention follow-up: None.

Higgins, S. T., Budney, A. J., Bickel, W. K., Foerg, F. E., Donham, R., & Badger, G. J. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51(7), 568–576. https://doi.org/10.1001/archpsyc.1994.03950070060011

Type of Study: Randomized controlled trial
Number of Participants: 40

Population:

  • Age — Voucher Group: Mean=31.8 years; No-Voucher Group: Mean=30.9 years
  • Race/Ethnicity — Voucher Group: 90% White; No-Voucher Group: 80% White
  • Gender — Voucher Group: 70% Male; No-Voucher Group: 65% Male
  • Status — Participants were cocaine-dependent adults recruited through the media and local professionals.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess whether incentives improved treatment outcomes in ambulatory cocaine-dependent patients. Participants were randomly assigned to receive the Community Reinforcement + Vouchers Approach (CRA+V) with vouchers equivalent to specified amounts of money contingent on negative urine tests or to Community Reinforcement Approach (CRA) without vouchers. Measures utilized include the Addiction Severity Index (ASI) and urinalysis. Results indicate that the CRA+V group maintained sobriety significantly longer than the no-voucher group, with 30% of participants reaching 20 weeks versus 5% for the no-voucher group. More participants in the CRA+V group also completed the full 24 weeks of treatment (75% versus 40%). Finally, at the end of treatment the CRA+V group had significantly better scores on the Drug Scale of the ASI and also showed improvement on the ASI Psychiatric Scale. Limitations include the lack of a no-treatment or standard-treatment control group, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Higgins, S. T., Budney, A. J., Bickel, W. K., Badger, G. J., Foerg, F. E., & Ogden, D. (1995). Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology, 3(2), 205–212. https://doi.org/10.1037/1064-1297.3.2.205

Type of Study: Randomized controlled trial
Number of Participants: 78

Population:

  • Age — Mean=30.3 years
  • Race/Ethnicity — Trial 1: 100% Caucasian; Trial 2: Voucher Group: 90% Caucasian, No-Voucher Group: 80% Caucasian
  • Gender — Trial 1: 100% Male; Trial 2: Voucher Group: 70% Male; No-Voucher Group: 65% Male
  • Status — Participants were cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same samples as Higgins et al. (1993) and Higgins, et al. (1994). The purpose of the study was to assess outcomes of two randomized controlled trials comparing the Community Reinforcement + Vouchers Approach (CRA+V) program to other treatments. Participants in Trial 1 were randomly assigned to receive either the CRA+V program or traditional initial individual counseling with later 12-step group attendance. Participants in Trial 2 were randomly assigned to CRA+V or CRA without vouchers. Measures utilized include urinalysis, self-reports, the Addiction Severity Index (ASI), and a structured interview. Results indicate that for Trial 1, significantly more participants in the CRA+V condition were abstaining from cocaine at 6, 9 and 12 months after treatment began than in the 12-step counseling condition and they were more likely to enter aftercare. There were no differences between groups in scores on the ASI. For Trial 2, both the CRA+V and non-voucher CRA groups showed equivalent rates of abstinence at 6, 9, and 12 months after treatment began and comparable ASI scores. However, more participants in the CRA+V group enrolled in aftercare. Limitations include the relatively small sample size and the absence of controls during the treatment follow-up period.

Length of controlled postintervention follow-up: 3 and 6 months.

Bickel, W. K., Marsch, L. A., Buchhalter, A. R., & Badger, G. J. (2008). Computerized behavior therapy for opioid-dependent outpatients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132–143. https://doi.org/10.1037/1064-1297.16.2.132

Type of Study: Randomized controlled trial
Number of Participants: 135

Population:

  • Age — Standard Treatment: Mean=30.1 years; Therapist-delivered CRA with Vouchers: Mean=26.1 years; Computer-assisted CRA with Vouchers: Mean=29.7 years
  • Race/Ethnicity — Standard Treatment: 98% White; Therapist-delivered CRA with Vouchers: 98% White; Computer-assisted CRA with Vouchers: 93% White
  • Gender — Standard Treatment: 58% Male; Therapist-delivered CRA with Vouchers: 56% Male; Computer-assisted CRA with Vouchers: 53% Male
  • Status — Participants were opioid-dependent adults recruited through the media, physicians, and drug and alcohol clinics.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the efficacy of a computer-based behavioral therapy intervention grounded in the CRA plus voucher-based contingency management model of behavior therapy. Participants were randomly assigned to either 1) therapist-delivered CRA treatment with vouchers [now called, Community Reinforcement + Vouchers Approach (CRA+V)], 2) computer-assisted CRA treatment with vouchers - a program containing the same essential elements but delivered via self-directed computer modules, or to 3) standard treatment. Measures utilized include urinalysis, the Addiction Severity Index (ASI), and the Helping Alliance Questionnaire-Patient Version (HAQ-P). Results indicate that the therapist-delivered and computer-assisted CRA+V conditions showed comparable rates of continuous abstinence (7.98 and 7.78 weeks on average, respectively) and significantly higher rates than the standard treatment (4.69 weeks on average). All groups showed similar rates of treatment retention and similar ASI and HAQ-P scores. Limitations include the lack of follow-up data to examine posttreatment outcomes.

Length of controlled postintervention follow-up: None.

Garcia-Rodriguez, O., Secades-Villa, R., Higgins, S. T., Fernandez-Hermida, J. R., Carballo, J. L., Perez, J. M. E., & Al-halabi Diaz, S. (2009). Effects of a voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 17(3), 131–138. https://doi.org/10.1037/a0015963

Type of Study: Randomized controlled trial
Number of Participants: 96

Population:

  • Age — Mean=28.4 years
  • Race/Ethnicity — Not specified
  • Gender — 89% Male
  • Status — Participants were enrolled in two outpatient treatment programs for cocaine dependence.

Location/Institution: Spain

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess whether voucher magnitude improved cocaine abstinence and retention in an outpatient treatment for cocaine dependence, and to determine the effectiveness of a contingency management intervention [now called Community Reinforcement + Vouchers Approach (CRA + Vouchers)] in a European cultural context. Participants were randomly assigned to one of three treatment conditions: standard outpatient treatment, CRA+Vouchers with low monetary vouchers, or CRA+Vouchers with high monetary vouchers. Measures utilized include the Michigan Alcoholism Screening Test, Beck Depression Inventory (BDI), the European version of the Addiction Severity Index (ASI), and urinalysis. Results indicate that in the standard treatment group, the mean percentage of cocaine-negative samples was 88.45%, versus 96.09% in the CRA plus low-vouchers group, and 97.07% in the CRA plus high-vouchers group. Retention rate at 6 months was 36.5% in the standard treatment group, 53.3% in the CRA plus low-vouchers group, and 69.0% in the CRA plus high-vouchers group. The CRA plus vouchers groups obtained better results than the standard program. Treating cocaine addiction by combining CRA with vouchers was more effective than standard treatment in community outpatient programs in Spain. Limitations include the lack of posttreatment follow-up and concerns over the between-clinics design because effectiveness between clinics could have been as great as effectiveness between groups.

Length of controlled postintervention follow-up: None.

Secades-Villa, R., Garcia-Rodriguez, O., Garcia-Fernandez, G., Sanchez-Hervas, E., Fernandez-Hermida, J. R., & Higgins, S. T. (2011). Community Reinforcement Approach Plus Vouchers among cocaine-dependent outpatients: Twelve-month outcomes. Psychology of Addictive Behaviors, 25(1), 174–179. https://doi.org/10.1037/a0021451

Type of Study: Randomized controlled trial
Number of Participants: 64

Population:

  • Age — Mean=28 years
  • Race/Ethnicity — 100% Hispanic
  • Gender — 87% Male and 13% Female
  • Status — Participants were enrolled in an outpatient treatment program for cocaine dependence.

Location/Institution: Spain

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of the Community Reinforcement plus Vouchers Approach (CRA+Vouchers) in a sample of individuals with cocaine dependence. Participants were randomly assigned to a CRA+Vouchers treatment group or standard care. Measures utilized include the Addiction Severity Index (ASI), Symptom Checklist-90-Revised (SCL-90-R), Michigan Alcohol Screening Test (MAST), Beck Depression Inventory (BDI), and regular urinalysis. Results indicate that the CRA+Vouchers treatment group completed a greater amount of treatment, demonstrated a higher rate of abstinence, and greater improvements in psychosocial functioning than the standard care comparison group. Limitations include the lack of post-intervention follow-up, the small sample size, lack of attrition data, and differences in the number of urine samples collected in weeks 1-12 between the two conditions.

Length of controlled postintervention follow-up: None.

Garcia-Fernandez, G., Secades-Villa, R., Garcia-Rodriguez, G., Alvarez-Lopez, H., Fernandez-Hermida, J. R., Fernandez-Artamendi, S., & Higgins, S. T. (2011). Long-term benefits of adding incentives to the Community Reinforcement Approach for cocaine dependence. European Addiction Research, 17(3), 139–145. https://doi.org/10.1159/000324848

Type of Study: Randomized controlled trial
Number of Participants: 58

Population:

  • Age — Not specified, minimum age=20 years
  • Race/Ethnicity — Not specified
  • Gender — CRA+Vouchers Group: 86% Male; CRA Group: 90% Male
  • Status — Participants were enrolled in an outpatient treatment program for cocaine dependence.

Location/Institution: Spain

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of the Community Reinforcement Plus Vouchers Approach (CRA+Vouchers) in a sample of individuals with cocaine dependence. Participants were randomly assigned to either a CRA+Vouchers group or a Community Reinforcement Approach (CRA) without vouchers group. Measures utilized include the Michigan Alcohol Screening Test (MAST), Beck Depression Inventory (BID), DSM-IV-TR Cocaine Dependence Criteria, European version of the Addiction Severity Index, Symptom Checklist-90-Revised, and urinalysis. Results indicate that significant improvements in psychosocial functioning occurred in both treatment groups, but when differences were observed, they supported CRA+Vouchers over CRA without vouchers. Limitations include that there were very few female cocaine users in the sample, the small sample size, which can limit ability to detect differences in retention and abstinence measures, and gap periods between urinalysis collections for cocaine abstinence, which threatens reliability.

Length of controlled postintervention follow-up: 6 months.

Additional References

Higgins, S. T., & Heil, S. H. (2024). Contingency management and the Community Reinforcement Approach. In S. Miller (Ed.). The ASAM principles of addiction medicine (7th ed., Ch. 73). Wolters Kluwer Health books. 

Higgins, S. T., Heil, S. H., & Peck, K. R. (2021). Substance use disorders, In D. H. Barlow (Ed.). Clinical handbook of psychological disorders (6th ed., Ch. 15). Guilford Press.

Lussier, J. P., Heil, S. H., Mongeon, J. A., Badger, J. G. & Higgins, S. T. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101(2), 192–203. https://doi.org/10.1111/j.1360-0443.2006.01311.x

Contact Information

Stephen T. Higgins, PhD
Website: archives.nida.nih.gov/sites/default/files/podat-3rdEd-508.pdf
Email:
Phone: (802) 656-9615
Fax: (802) 847-4891

Date Research Evidence Last Reviewed by CEBC: April 2024

Date Program Content Last Reviewed by Program Staff: April 2024

Date Program Originally Loaded onto CEBC: August 2006