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School of Medicine
The Center for Learning and Health (CLH) is a treatment research unit dedicated to developing and evaluating behavioral interventions that address the interrelated problems of drug addiction, poverty, and health. CLH was established in 1996 and has served as the site of many NIH-funded clinical trials. CLH is located in the west tower of the Mason F. Lord Building on the Johns Hopkins Bayview Medical Center campus in Baltimore, Maryland (campus map and directions to campus).
Our mission is to improve the health and well-being of low-income individuals and families by conducting the highest quality behavioral research, providing life-changing behavioral treatments, and educating the next generation of behavioral scientists.
We are striving to create economically feasible and sustainable behavioral interventions that alleviate poverty and promote life-long health.
The Therapeutic Workplace
The majority of the research conducted at CLH has been directed toward developing and evaluating a novel employment-based intervention called the therapeutic workplace. The therapeutic workplace is a motivational intervention that uses access to employment and wages to reinforce therapeutic behavior change. Under this intervention, unemployed adults living in poverty earn the opportunity to work and earn wages by meeting treatment goals such as maintaining drug abstinence and adhering to prescribed medications. The therapeutic workplace has been recognized by the Substance Abuse and Mental Health Services Administration’s National Registry of Effective Programs and was recognized by the White House Office of National Drug Control Policy (ONDCP) as a model innovation for the treatment of drug addiction.
Since our research participants generally lack the skills or credentials needed to obtain gainful employment, the therapeutic workplace intervention is designed to be delivered in two phases. In phase one, participants initiate drug abstinence and learn academic and job skills. In phase two, participants maintain drug abstinence and work in actual jobs. CLH operates a learning center that provides the necessary academic and job skills training during phase one. Our training is individualized, most of it is computerized, and all of the training employs state-of-the-art teaching methods that are effective in a wide range of populations. Trainees in the learning center typically work for four hours every weekday for six or seven months. We provide training stipends that are contingent on attendance and performance on training programs. Participants who acquire sufficient skills are referred to community employment or hired in our in-house model data entry business. A recent analysis showed that CLH provides over 20,000 hours of computerized training and employment annually.
A number of randomized controlled clinical trials and other controlled studies have demonstrated that the therapeutic workplace can:
- Increase abstinence from cocaine, heroin, and alcohol in unemployed refractory drug users.
- Maintain drug abstinence over long time spans.
- Reduce drug-related HIV risk behaviors in injection drug and crack cocaine users.
- Promote the use of the opiate antagonist naltrexone in heroin dependent adults.
- Engage low-income adults in education and job skills training, and establish critical academic and job skills.
- Evaluating the effectiveness of the therapeutic workplace in promoting adherence to extended-release naltrexone and abstinence from heroin in heroin-dependent adults.
- Developing ways to link the therapeutic workplace to the criminal justice system as an alternative to incarceration.
- Developing ways to enhance the long-term abstinence and employment outcomes of our participants by providing wage subsidies for community employment, and by linking directly with collaborative employers.
- Developing and evaluating ways to promote suppression of viral load in people living with HIV
The Conceptual Foundation of Our Research
Extensive evidence conducted in basic research laboratories and in clinical settings has demonstrated that much of human behavior is operant in nature. Operant behavior is any behavior that is sensitive to the effects of its consequences. Most of our research has applied this operant model of human behavior to the treatment of drug addiction. Over 50 years of research has demonstrated unequivocally that drug taking can be modified by changes in the environment and effectively treated through the application of the principles of operant conditioning. CLH is devoted to developing interventions that apply these principles to change existing behaviors and to build new behaviors needed for a healthy lifestyle.
CLH seeks to provide rich and rewarding educational experiences to postdoctoral fellows, graduate and medical school students, undergraduates, and high school students. Postdoctoral fellows can take lead roles in conducting randomized controlled clinical trials and conduct independent research projects. Graduate students can conduct thesis and dissertation research, engage in independent study, and complete clinical internships. Undergraduate students can complete internships, receive supervised practicum experience, and conduct research projects. Our training qualifies toward fulfilling the experience requirement of the Behavior Analyst Certification Board. Contact our Director for more information regarding educational opportunities.
Collaborators in the Department of Psychiatry and Behavioral Sciences
Collaborators in the Department of Medicine
Collaborating Organizations in the School of Medicine
Center for Learning and Health
5200 Eastern Avenue, Suite 142 West
Baltimore, MD 21224
Holtyn AF, Koffarnus MN, DeFulio A, Sigurdsson SO, Strain EC, Schwartz RP, & Silverman K. Employment-based abstinence reinforcement promotes opiate and cocaine abstinence in out-of-treatment injection drug users. Journal of Applied Behavior Analysis. 2014; 47(4):681-693.
Holtyn AF, Koffarnus MN, DeFulio A, Sigurdsson SO, Strain EC, Schwartz RP, Leoutsakos JM, & Silverman K. The therapeutic workplace to promote treatment engagement and drug abstinence in out-of-treatment injection drug users: A randomized controlled trial. Preventive Medicine. 2014; 68:62-70.
DeFulio A, Everly JJ, Leoutsakos JS, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Employment-based reinforcement of adherence to an FDA approved extended release formulation of naltrexone in opioid-dependent adults: A randomized controlled trial. Drug Alcohol Depend. 2012;120(1-3):48-54.
Koffarnus MN, Wong CJ, Diemer K, Needham M, Hampton J, Fingerhood M, Svikis D, Bigelow GE, Silverman K. A randomized clinical trial of a therapeutic workplace for chronically unemployed, homeless, alcohol-dependent adults. Alcohol Alcohol. 2011; 46(5):561-569.
Everly JJ, DeFulio A, Koffarnus MN, Leoutsakos JM, Donlin W, Aklin WM, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Employment-based reinforcement of adherence to depot naltrexone in unemployed opioid-dependent adults: A randomized controlled trial. Addiction. 2011; 106(7):1309-1318.
DeFulio A, Silverman K. Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: post-intervention outcomes. Addiction. 2011;106(5):960-967.
DeFulio A, Donlin WD, Wong CJ, Silverman K. Employment-based abstinence reinforcement as a maintenance iIntervention for the treatment of cocaine dependence: A randomized controlled trial. Addiction. 2009;104(9):1530-1538.
Silverman, K, Wong, CJ, Needham, MJ, Diemer, KN, Knealing, TW, Crone-Todd, D, Fingerhood, M, Nuzzo, P, & Kolodner, K. A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. Journal of Applied Behavior Analysis. 2007; 40: 387-410.
Silverman K, Wong CJ, Grabinski MJ, Hampton J, Sylvest CE, Dillon EM, Wentland RD. A web-based therapeutic workplace training program and business for the treatment of drug addiction and chronic unemployment. Behavior Modification. 2005; 29: 417-463.
Silverman K. Exploring the limits and utility of operant conditioning in the treatment of drug addiction. The Behavior Analyst. 2004; 27: 209-230.
Silverman K, Svikis D, Wong CJ, Hampton J, Stitzer ML, Bigelow GE. A reinforcement-based therapeutic workplace for the treatment of drug abuse: 3-year abstinence outcomes. Experimental and Clinical Psychopharmacology. 2002; 10: 228-240. (Special Issue on Substance Abuse Treatment).
Silverman K, Svikis D, Robles E, Stitzer ML, Bigelow GE. A reinforcement-based therapeutic workplace for the treatment of drug abuse: 6-month abstinence outcomes. Experimental and Clinical Psychopharmacology. 2001; 9: 14-23.
Silverman K, Higgins ST, Brooner RK, Montoya ID, Cone EJ, Schuster CR, Preston KL. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry. 1996; 53: 409-415.