Treatment Responsivity of Cocaine-Dependent Patients With AntisocialPersonality Disorder to Cognitive–Behavioral and ContingencyManagement InterventionsNena Messina, David Farabee, and Richard RawsonUniversity of California, Los AngelesThis study compared the efficacy of 2 approaches for the treatment of cocaine dependence amongmethadone-maintained patients with and without antisocial personality disorder (ASPD). Patients wererandomly assigned to 4 study conditions: cognitive–behavioral treatment (CBT), contingency manage-ment (CM), CBT with CM, or methadone maintenance. The Structural Clinical Interview for MentalDisorders–IV was administered to 108 patients to assess ASPD. A 2-way analysis of variance showedthat patients with ASPD were more likely to abstain from cocaine use during treatment than patientswithout 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 responsivitywhile controlling for other factors.The essential feature of antisocial personality disorder (ASPD)is a pervasive pattern of disregard for the rights of others (Diag-nostic and Statistical Manual of Mental Disorders, 4th ed.; DSM–IV; American Psychiatric Association, 1994). People with ASPDhave minimal inhibitions about committing criminal acts, theyhave little or no fear of impending punishments, and they are oftenimpulsive and aggressive (Davison & Neale, 1990). This disorderis 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 ASPDbeing substance abusers (Gerstley, Alterman, McLellan, &Woody, 1990).The recurring association among ASPD, substance abuse, andcrime has led to a variety of treatment outcome evaluations forsubstance abusers with this disorder. In light of the prevalence ofASPD among substance-abusing populations, it became impera-tive that effective treatment strategies be identified. However,there is a widely held belief among treatment providers thatpersons with ASPD do not respond well to treatment as a directresult of the symptoms of their disorder (Abram, 1989; Evans &Sullivan, 1990; Forrest, 1992). This belief was substantiated by afrequently cited report that stated that, compared with other typesof patients, antisocial opioid abusers responded poorly to bothroutine drug abuse counseling and specialized psychotherapy(Woody, McLellan, Luborsky, & O’Brien, 1985).However, results from more recent studies that have empiricallyassessed the relationship between ASPD and substance abusetreatment outcomes have not supported the previous findings re-garding this disorder and treatment response (Brooner, Kidorf,King, & Stoller, 1998; Gil, Nolimal, & Crowley, 1992; Messina etal., 1999; Silverman et al., 1998). Gil et al. (1992) compared thetreatment outcomes of 55 consecutively admitted methadonemaintenance patients with ASPD (42%) and those without ASPD.Although the findings were limited by the small sample andambiguous design, no significant differences were found betweenthose with and those without ASPD on any 12-month outcomevariable (e.g., treatment retention, urine-test results, therapy ses-sion attendance). It appeared that ASPD patients did as well asthose without ASPD in a traditional methadone maintenance pro-gram. However, a lack of difference did not necessarily implygood treatment responsivity. The authors reported low overallretention in this sample of clients.Valliant (1975) had previously speculated that structured behav-ioral programs with incentives for participation might produce thebest results for antisocial opioid patients. Evans and Sullivan(1990) also stated that “[it] is highly unlikely that antisocials willdevelop genuine remorse and altruistic reasons for staying cleanand sober. However, they may be interested if it will help them winat poker, make more money, or stay out of jail” (p. 104).Brooner et al. (1998) directly tested Valliant’s hypothesis re-garding the use of incentives. Forty opioid abusers with co-occurring ASPD were randomly assigned to an experimental treat-ment condition combining methadone maintenance (MM) andcontingency management (CM) techniques (i.e., a structural be-havioral intervention using rapid delivery of positive and negativecontingencies) or a control condition (i.e., standard MM). In theexperimental condition, take-home methadone doses and dosealterations were contingent on drug-free urine specimens andcounseling session attendance. Preliminary findings did not revealNena Messina, David Farabee, and Richard Rawson, Integrated Sub-stance Abuse Programs, University of California, Los Angeles.This project was supported by the National Institute on Drug AbuseGrant DA 094119. We are grateful to the staff and the patients at the MatrixInstitute and the West Los Angeles Treatment Program for their partici-pation. 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 NenaMessina, Integrated Substance Abuse Programs, University of California,11050 Santa Monica Boulevard, Suite 150, Los Angeles, California 90025.E-mail: [email protected] of Consulting and Clinical Psychology Copyright 2003 by the American Psychological Association, Inc.2003, Vol. 71, No. 2, 320–329 0022-006X/03/$12.00 DOI: 10.1037/0022-006X.71.2.320320significant differences between the groups, yet both groupsshowed marked reductions in heroin and cocaine use during the17-week outcome evaluation. The authors contended that thesefindings were contrary not only to what is commonly thoughtabout ASPD clients in traditional methadone treatment but also towhat is commonly thought about ASPD clients in enhanced meth-adone (i.e., MM combined with CM) treatment programs as well.However, this study was limited by a small sample and by theabsence of a non-ASPD control group.Other CM approaches include giving vouchers that are ex-changeable for goods and services in response to drug-free urinespecimens. Silverman et al. (1998) compared the treatment respon-siveness of 59 MM patients with ASPD (19%) and without ASPDwho were participating in voucher-based cocaine abstinence rein-forcement therapy. Patients were randomly assigned to one of