Journal of Consulting and Clinical Psychology 2003 Vol 71 No 2 320 329 Copyright 2003 by the American Psychological Association Inc 0022 006X 03 12 00 DOI 10 1037 0022 006X 71 2 320 Treatment Responsivity of Cocaine Dependent Patients With Antisocial Personality Disorder to Cognitive Behavioral and Contingency Management Interventions Nena Messina David Farabee and Richard Rawson University of California Los Angeles This study compared the efficacy of 2 approaches for the treatment of cocaine dependence among methadone maintained patients with and without antisocial personality disorder ASPD Patients were randomly assigned to 4 study conditions cognitive behavioral treatment CBT contingency management CM CBT with CM or methadone maintenance The Structural Clinical Interview for Mental Disorders IV was administered to 108 patients to assess ASPD A 2 way analysis of variance showed that patients with ASPD were more likely to abstain from cocaine use during treatment than patients without ASPD The strong treatment effect for ASPD patients was primarily due to the CM condition Regression analyses showed that ASPD remained significantly related to CM treatment responsivity while controlling for other factors routine drug abuse counseling and specialized psychotherapy Woody McLellan Luborsky O Brien 1985 However results from more recent studies that have empirically assessed the relationship between ASPD and substance abuse treatment outcomes have not supported the previous findings regarding this disorder and treatment response Brooner Kidorf King Stoller 1998 Gil Nolimal Crowley 1992 Messina et al 1999 Silverman et al 1998 Gil et al 1992 compared the treatment outcomes of 55 consecutively admitted methadone maintenance patients with ASPD 42 and those without ASPD Although the findings were limited by the small sample and ambiguous design no significant differences were found between those with and those without ASPD on any 12 month outcome variable e g treatment retention urine test results therapy session attendance It appeared that ASPD patients did as well as those without ASPD in a traditional methadone maintenance program However a lack of difference did not necessarily imply good treatment responsivity The authors reported low overall retention in this sample of clients Valliant 1975 had previously speculated that structured behavioral programs with incentives for participation might produce the best results for antisocial opioid patients Evans and Sullivan 1990 also stated that it is highly unlikely that antisocials will develop genuine remorse and altruistic reasons for staying clean and sober However they may be interested if it will help them win at poker make more money or stay out of jail p 104 Brooner et al 1998 directly tested Valliant s hypothesis regarding the use of incentives Forty opioid abusers with cooccurring ASPD were randomly assigned to an experimental treatment condition combining methadone maintenance MM and contingency management CM techniques i e a structural behavioral intervention using rapid delivery of positive and negative contingencies or a control condition i e standard MM In the experimental condition take home methadone doses and dose alterations were contingent on drug free urine specimens and counseling session attendance Preliminary findings did not reveal The essential feature of antisocial personality disorder ASPD is a pervasive pattern of disregard for the rights of others Diagnostic and Statistical Manual of Mental Disorders 4th ed DSM IV American Psychiatric Association 1994 People with ASPD have minimal inhibitions about committing criminal acts they have little or no fear of impending punishments and they are often impulsive and aggressive Davison Neale 1990 This disorder is also strongly associated with substance abuse with about 40 to 50 of substance abusers meeting the criteria for ASPD Messina Wish Nemes 1999 Tims DeLeon Jainchill 1994 and approximately 90 of persons diagnosed with ASPD being substance abusers Gerstley Alterman McLellan Woody 1990 The recurring association among ASPD substance abuse and crime has led to a variety of treatment outcome evaluations for substance abusers with this disorder In light of the prevalence of ASPD among substance abusing populations it became imperative that effective treatment strategies be identified However there is a widely held belief among treatment providers that persons with ASPD do not respond well to treatment as a direct result of the symptoms of their disorder Abram 1989 Evans Sullivan 1990 Forrest 1992 This belief was substantiated by a frequently cited report that stated that compared with other types of patients antisocial opioid abusers responded poorly to both Nena Messina David Farabee and Richard Rawson Integrated Substance Abuse Programs University of California Los Angeles This project was supported by the National Institute on Drug Abuse Grant DA 094119 We are grateful to the staff and the patients at the Matrix Institute and the West Los Angeles Treatment Program for their participation We thank Alice Huber Christie Thomas Vikas Gulati Al Hasson and Michael McCann for their assistance with the conduct of this study Correspondence concerning this article should be addressed to Nena Messina Integrated Substance Abuse Programs University of California 11050 Santa Monica Boulevard Suite 150 Los Angeles California 90025 E mail nmessina ucla edu 320 RESPONSIVITY OF COCAINE DEPENDENT PATIENTS significant differences between the groups yet both groups showed marked reductions in heroin and cocaine use during the 17 week outcome evaluation The authors contended that these findings were contrary not only to what is commonly thought about ASPD clients in traditional methadone treatment but also to what is commonly thought about ASPD clients in enhanced methadone i e MM combined with CM treatment programs as well However this study was limited by a small sample and by the absence of a non ASPD control group Other CM approaches include giving vouchers that are exchangeable for goods and services in response to drug free urine specimens Silverman et al 1998 compared the treatment responsiveness of 59 MM patients with ASPD 19 and without ASPD who were participating in voucher based cocaine abstinence reinforcement therapy Patients were randomly assigned to one of two levels of voucher based interventions or to a control group in which vouchers were given on a noncontingent basis The