Contingency Management in Substance Abuse Treatment

Transcription

1 Contingency Management in Substance Abuse Treatment Bailey P. MacLeod, PhD, LPC Agenda Why Contingency Management Behavioral Principles History Research Examples Clinical Application Substance Abuse Treatment Today What s working? What s not working? Awareness/Stigma Treatment Outcomes Availability of Treatment Prevention Research Interventions 1

2 Motivational Incentives Are used as a tool to enhance treatment and facilitate recovery Target specific behaviors that are part of a patient treatment plan Celebrate the success of behavioral changes chosen by therapist and patient Are used as an adjunct to other therapeutic clinical methods Can be used to help motivate patients through stages of change to achieve an identified goal Are a reward to celebrate the change that is achieved Why Contingency Management? Have you used incentives? What types? What do you know about CM and Motivational Incentives? Why do you think you might want to use them? Agency Directors Considerations Minimum investment for increased retention Adoption of an evidence-based practice Limited training Motivates staff (possible retention) Provides a fun environment Promotes teamwork 2

3 Some Observations Health and Hospitals Corporation (HHC) in New York after instituting Motivational Incentives: Patients began to show increases in self-esteem, improvements in appearance and self-care, and a more goal-oriented perspective. Patients became motivated toward a recovery managed lifestyle. Some patients were reunited with estranged family and friends. Patients reestablished values and goals for long term healthy lifestyle. Counselors believed that the patients began to take on a greater sense of responsibility for their recovery; they went from You are forcing me to I choose. The staff and patients that were initially resistant were encouraged when they saw and experienced positive changes. Policy Maker Considerations Minimum investment for reduced substance use People engaged in treatment longer Reduction in societal costs Minimal training to implement Societal Benefits Recent cost benefit studies consistently find that benefits to society (i.e., decreased crime, improved health, increased employment, increased overall social functioning) are greater than the costs of addictions treatment (Harwood, 2002) Addictions treatment has been shown to cut drug use in half, reduce crime by 80% and reduce arrests up to 64% (SAMHSA, 1997) For every additional dollar invested in addictions treatment, the taxpayer saves at least $7.46 in costs to society (including the cost of incarceration) (Rydell & Everingham, 1994) When adding the savings to healthcare, for every $1 spent in addictions treatment, society benefits by greater than $12 (NIDA, 1999) For every $1 the US Government spends on addictions treatment it saves $7 to $25 in other costs (SAMHSA, 2002) 3

4 Clinical Staff Considerations Opportunity to celebrate success Tool to help patients achieve goals empowerment Increases patient cohesiveness Encourages participation with ancillary services Increases retention Reduces substance use Back to Basics Behavioral Theory Human behavior is learned Substance abuse is learned through operant and classical conditioning Addiction is defined by four key elements 1. Access to substances in the environment 2. Positive reinforcement is experience from drug use 3. Lack of positive reinforcement for alternative behaviors 4. Lack of immediate punishment for drug use Use discontinues when: Punishers that follow ingestion become immediate Rewards for abstinence are realized Behavioral Theory 3 Classes of Reinforcers: Euphoria Social Variables Elimination of Withdrawal Addiction is maintained because other adaptive behaviors are not reinforced Relapse occurs because drugs are available and always work Physical dependence is not necessary nor sufficient for addiction 4

5 Behavioral Terms Generalization Discrimination Extinction Positive/Negative Reinforcement Positive/Negative Punishment Addiction: Immediate reward and delayed negative consequences Reinforcement vs. Punishment Reinforcement/Punishment Positive Reinforcement Presentation of reinforcing stimuli after a target behavior occurs Negative Reinforcement Removal of aversive stimuli after target behavior occurs Positive Punishment Presentation of aversive stimuli after undesirable behavior Negative Punishment Removal of positive condition after undesirable behavior 5

6 Reward vs. Reinforcement Motivational Incentives vs. Contingency Management Motivational Incentives vs. Motivational Interviewing 6

7 Operant Conditioning vs. Classical Conditioning Substance User s Dilemma What are incentives for substance abusing clients to continue use? What are some incentives for them to discontinue? Continue Use Quick money Spend time with friends Avoid painful feelings Euphoria Cope Recovery Employment Family Health Money Avoid legal issues Behavioral Economics (Correia et al., 2010) Behavior Choice Theory Frequency of a behavior depends on its reinforcement relative to the reinforcement obtained from alternative behaviors Primary influence on drug use includes access to drugs and value of other non-substance reinforcers in environment Cost-Benefit analysis Factors that influence drug and non-drug behavior: Price (i.e., money, time, energy, health, legal) Time (delays in receiving reinforcers) Delay Discounting Decrease in value of reinforcement of behavior as time from behavior to reward increases Long-term higher rewards of abstaining are discounted relative to the immediate rewards of drug use 7

8 Contingency Management Make recovery a more attractive option through positive reinforcement of abstinencecongruent behaviors Applying behavioral principles to change substance use Reinforcers increase desired behavior Punishment and sanctions decrease undesired behavior Goal is to weaken drug using behavior and strengthen abstinence behavior Treatment of Cocaine Dependence Treatment as Usual Incentive 25 0 Retained through 6 month study 8 weeks of Cocaine abstinence Higgins et al.,

9 Treatment of Cocaine Dependence (Higgins et al., 1993) Voucher-Based Reinforcement Treatment (VBRT) Escalating schedule with reset penalty using drug screens Trade in points for goods $1000 available in first 3 months Treatment of Cocaine Use in Methadone Clients Treatment as Usual Incentive 25 0 Retained through 6 month study 8 weeks of Cocaine abstinence Silverman et al., 1996 Retention Treatment as Usual Incentive Weeks Petry et al.,

10 Percent Positive for Any Illicit Drug Percent Treatment as Usual Incentive 10 0 Intake Week 4 Week 8 Petry et al., 2000 Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) Randomly assigned 800 clients to receive treatment with incentives Eligibility: Stimulant abusers randomly assigned to treatment as usual and treatment as usual plus incentives How: Sample urine collection occurred twice weekly. Drug-free urine samples for stimulants resulted in draws from a box or fishbowl increasing in number for each week of continuous drug-free urine samples. 2 Bonus draws were given for negative marijuana and/or opiate Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) Improved Retention in Counseling Treatment Percentage Retained Treatment as Usual Incentive Study Week Petry, Peirce, Stitzer, et al

11 Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) Incentives Improve Outcomes in Methamphetamine Users Percentage of drug-free urine samples Week Treatment as Usual Treatment as Usual plus Incentives Roll, et al Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) Percentage of stimulant drug-free samples Incentives Reduce Stimulant Use in Methadone Maintenance Treatment Study Visit Treatment as Usual Treatment as Usual plus Incentives Peirce, et al CM Research (Fitzsimons et al., 2015) Examined impact of low-cost contingency management (CM) on treatment attendance and utilization for clients in outpatient SA treatment Reinforcement-Based Therapy (RBT) only vs RBT+CM RBT Only: Group Individual counseling Vocational assistance Meal vouchers for treatment attendance Eligible for once weekly lottery style drawing for prizes Prizes ranged from positive affirmations to $10 gift card 11

12 CM Research (Fitzsimons et al., 2015) RBT+CM Group: RBT as usual Clients received $10 incentive for coming to treatment day after intake and a $15 incentive on 5 th day of treatment attendance Results RBT+CM and RBT returned on day 1 at similar high rates (95% vs 89%) RBT group less likely to attend after intake RBT+CM attended significantly more treatment days, attended more individual counseling sessions, had higher rates of overall treatment utilization CM Research-Heroin Abusers (Jones et al., 2005) Examined efficacy of RBT for abstinence over 12 months of opioid-dependent clients exiting detox program Two groups: RBT and TAU RBT Group: Paid recovery housing Recreational Activities Group/Individual counseling Vocational Training Meals Maximum possible cost per abstinent person $2294 Average cost over 3 months per person: $510 CM Research-Heroin Abusers (Jones et al., 2005) If positive urine screens, reinforcements were temporarily removed, including housing, until abstinence was established Results RBT had higher abstinence at 1 month (42% vs 15%) and 3 months (38% vs 17%), but not at 6 or 12 months RBT group showed significant increases in number of days worked and amount of legal income earned at 3, 6, and 12 months 12

13 CM and Long-Term Improvements (Petry et al., 2014) Purpose: Examine association between engaging in jobrelated activities and indices of substance use and psychosocial functioning Participants were monitored for abstinence and non-drug related activities (i.e, employment) Participants received reinforcement for: Abstinence Completing job related activities Job-related activities Identifying jobs, developing a resume, completing job applications, attending job interview, going to work, job training CM and Long-Term Improvements (Petry et al., 2014) Results: Those who completed two or more job-related activities as week during treatment had significantly less severity of employment problems Completing employment activities significantly associated with improvements in quality of life, longer duration in treatment, and continuous abstinence CM for Dual Diagnosis Dual-Diagnosis patients in IOP for 6 weeks (Kelly, Daley, & Douaihy, 2014) CM used for treatment attendance and abstinence CM patients attended more treatment days than non-cm group No difference in number of drug-free days Days attending treatment partially mediated the relationship between CM exposure and drug-free days Exposure to CM increases retention in treatment, which contributes to increased drug-free days 13

14 CM for Dual Diagnosis (Petry, Alessi, & Rash, 2013) Purpose: Examine the impact of CM on psychiatric symptoms of cocaine dependent clients receiving CM with standard care vs. standard care alone CM clients were reinforced for abstinence and completion of treatment activities CM significantly reduced psychiatric symptoms compared to the TAU group Symptoms of interpersonal sensitivity, depression, hostility, phobic anxiety, and psychoticism Effects of CM on reducing psychiatric symptoms are mediated by reductions in drug use Reductions in psychiatric symptoms were seen throughout the 9-month follow-up period Principles of CM CM includes 3 basic tenets: Arrange the environment so target behaviors are detected Tangible reinforcers are given when target behavior is demonstrated Incentives are withheld when target behavior does not occur 7 Core Principles: The target behavior The target population The type of reinforcer The magnitude/amount of incentive Frequency of incentive distribution Timing of the distribution of the reinforcement Duration of the reinforcement intervention Identifying Target Behaviors Something that is problematic and needing to change Must be observable and measurable Examples? Drug Abstinence Compliance with Treatment Plans/Goals Clinic Behaviors Medication Compliance Attendance 14

15 Identifying Target Behaviors Drug Abstinence Goal is to detect all instances of use of target drug(s) CM studies typically monitor drug use 2-3 times a week Negative drug screen = reinforcer Positive drug screen = no reinforcer and/or punisher Recommend use of on-site test kits Identifying Target Behaviors Drug Abstinence Issues: Cost, testing for multiple substances, need to do observed drug screens Check urine temperature, dilution, and ph for validity Lag time between abstinence and negative readings (i.e., marijuana) Detox before entering CM treatment recommended Alcohol detection is problematic due to short intervals of detection Some clients do not achieve significant drug-free period in CM studies Reinforcer may be too small to compete with drug use Response requirement may be too high Identifying Target Behaviors Compliance with Treatment Plans/Goals Reinforcing behaviors that compete with substance use Reinforcing compliance with steps toward treatment goals Clients can decide on three discrete activities each week Break down larger treatment goals into smaller stepsreinforce completion of the steps Examples: Goal: Improve health Behavior: Attend medical appointment Goal: Employment Behavior: Completing job application 15

16 Identifying Target Behaviors Compliance with Treatment Plans/Goals Benefits Iguchi et al. (1997) found that reinforcement of activities was more effective in reducing drug use compared to reinforcing abstinence only Focus on what clients could do rather than on just drug use or what they are doing wrong Inexpensive May improve psychosocial functioning Issues Need to be skills in breaking down goals into measurable steps Need to verify activity completion objectively Identifying Target Behaviors Clinic Behaviors & Attendance Reinforcing attendance to treatment can increase treatment participation Within-clinic behaviors to reinforce pro-social behaviors Rather than just punishing negative behaviors (i.e., swearing, complaining) Medication Compliance Medication that can benefit recovery (naltrexone, psychiatric meds, HIV medication) Issue: Difficult to monitor daily use objectively Identifying Target Population May not need to use for all clients Can help cut costs associated with CM What are examples of criterion used for who should and should not get CM? Examples: New clients to increase early retention Clients unsuccessful in past treatment High risk populations (HIV, pregnant women) Critical time points in treatment for high risk of relapse/drop out (early treatment, transitions, 90-day mark) 16

17 Choice of Reinforcers Critical Component!! Incentives that have higher value to the population will have greater impact on behavior Examples?? Vouchers/Escalating Vouchers Cash On-Site Retail Stores Variable Ratio Reinforcers/Prizes (Fishbowl) Clinic Privileges Employment and Housing Informing Refunds/Rebates Public Assistance and Financial Management Choice of Reinforcers Vouchers and Escalating Vouchers Negative urine sample earns a voucher, which accumulates in accounts Voucher can escalate as number of consecutive negative urine samples increases (first=$2.50, second=$3.75, third=$5); vouchers reset at beginning for positive drug tests Vouchers can be redeemed for items at client s request Typical requests: restaurant gift cards, clothing, haircuts, movie theater tickets, bills Highly accepted by clients-fewer than 5% have refused participation Choice of Reinforcers Vouchers and Escalating Vouchers Criticisms/Issues Expensive to employ and manage Some studies included earnings for as much as $1000, with the average earning of $600 Staff time needed to obtain requested items or provide transportation 17

18 Choice of Reinforcers Cash Rather than vouchers to reinforce target behaviors Less expensive than vouchers due to less staff time to obtain voucher items Criticisms Fear that money will be used to buy drugs/alcohol Need to raise the funds Choice of Reinforcers On-Site Retail Stores Items already available to redeem with vouchers Easier to implement Items can be donated from community/local retailers Rowan-Szal et al. (1994): program where methadone clients could earn stars for negative drug screens that could be exchanged for low cost items (gas vouchers, coffee mug) Important to stock items based on client s interests Choice of Reinforcers Clinic Privileges Methadone program- take home doses Inpatient/Residential treatment-access to new activities, overnight stays, outings Employment and Housing Used to address psychosocial problems and addiction Requires significant start-up costs for housing, employment options, and training services Informing Specifying aversive consequence for drug use, like informing an employer, legal authority, or licensing board Positive consequence for target behavior can be informing others of attendance and abstinence 18

19 Choice of Reinforcers Refunds/Rebates Clients pay a fee upon treatment entry, which is refunded for target behavior May be difficult to entice clients into program Not practical with underprivileged populations Reduce fees for service or provide rebate of treatment cost May not be feasible if using insurance Public Assistance and Financial Management Provide public assistance or establish a representative payee who handle finances Allow greater independence of client s own finances with abstinence/treatment completion Can help with stable housing and teaching clients financial management skills Choice of Reinforcers Variable Ratio Reinforcers/Prizes (Fishbowl) Considered a low-cost incentive Only reinforce a proportion of target behaviors Fishbowl Method-clients select a slip of paper from a fish bowl after target behavior Behavior is rewarded immediately Client exchanges prize slip for a selected prize Choice of Reinforcers Fishbowl Method Half of the slips have positive affirmations Good Job! Other half are winners of prizes (say, Small, Medium, Large): 1/2 Small prize ($1) 1/16 Medium prize ($20) 1/250 Jumbo prize ($100) Average cost per client $200 Patients are allowed to select an increasing number of draws each time they reach an identified goal. Patients may get one draw for the first drug-free urine sample, two draws for the second drug-free urine, and so on. Patients will lose the opportunity to draw a prize with a positive urine screen, but are encouraged and supported. When they test drug-free again, they can start with one draw. 19

20 Incentive Magnitude Higher magnitude reinforcers increase behaviors Certain other behavioral principles may achieve positive outcomes for lower magnitude reinforcers (such as variable ratio schedule) Choose reinforcer that can compete with reinforcement derived from the behavior targeted for change, which can be reduced once the new behavior has been established Example: $25 for drug abstinence, $1 for being on time Consider this, what if you were offered a dime as an incentive for every 5 miles driven within the posted speed limit; would that change your behavior? Maybe a dime is not enough. The reward would have to be given often enough and be large enough to compete with the reasons you have for speeding. Frequency of Incentive Frequency of occurrence of target behavior, monitoring schedule, and reinforcement Need target behavior to occur frequently in order to receive reinforcer in order to increase the association between behavior and reinforcer The schedule is based on many variables: Target behavior Resources Amount of clinical contact How often you want to reinforce the behavior Secondary reinforcement of Fishbowl method Reinforce more frequently at first and reduce as behavior is better established Timing of the Incentive Time between verification of target behavior and reinforcer Learning occurs best when target behavior is immediately followed by reinforcer Research has shown that clients who have to wait longer periods of time to exchange vouchers for retail items achieved less abstinence than clients who had more rapid exchange (Rowan-Szal et al., 1994) On-site testing systems have better outcomes than off-site testing systems (Schwartz et al., 1987) Value of reinforcer decreases with time $100 delivered in one week may be equally preferred to $95 delivered now Substance abusers have significantly truncated time horizons (Petry et al., 1998) and discount delayed rewards at 2-4 times the rate of controls 20

21 Duration of CM Intervention Most studies of CM for 8-12 weeks Clients will need to internalize the recovery process and find or develop naturally-occurring reinforcers that will support their recovery-based and nonaddict identities (Biernacki, 1986; Kellogg, 1993; see also Lewis & Petry, 2005) Duration is connected to relapse Research is mixed, but some clients return to pre-intervention levels of drug use Paradoxical results: Shows the intervention works Adapt duration to client behavior Increase requirements to receive incentive and decrease magnitude of incentive Some may need indefinite duration Special Considerations Behavioral Contracting Outlines upfront the behaviors monitored, schedule of monitoring, and contingencies to be imposed Individual or clinic-wide Example: Client who is consistently late can be contracted for being on time with reinforcers Objectively Quantified Behaviors Need to be able to verify and monitor behaviors Is it Objective and Verifiable?? Drug Test Results Showing a positive attitude Client reports that they went to an AA meeting Client s spouse says client has been abstinent Employment Attended group counseling Completed homework Doctor s note Showing commitment to recovery Client avoided old using buddies 21

22 Special Considerations Consistency Tendency of staff to decrease frequency of applying contingencies or monitoring behaviors Programs need to promote staff adherence to CM through weekly progress reports, daily charts/checklists, delegating tasks Successive Approximations Reinforcing for approximation to target behavior Qualitative measures of substances in drug tests to show decrease in use Assigning simple activities early on in treatment Example: Making doctor s appointment before attending appointment Special Considerations Priming Providing early access to reinforcers Giving client a bus ticket at initial entry into treatment program Escalating Reinforcers and Bonuses Increasing the magnitude of the reinforcer as target behavior continues Longer periods of abstinence associated with increase value of vouchers Research shows that escalating system resulted in longer periods of abstinence than constant rate of reinforcement (even though both groups had equivalent maximal reinforcement); shows that escalating system may be necessary for inducing significant periods of abstinence Bonuses for a certain number of continuous target behaviors can be a helpful incentive Checklist for Designing CM Programs Step 1: Choose Behavior Quantified objectively and occur frequently Do not ask too much at once, select most important behaviors Step 2: Choose a Reinforcer Must be maintained and available Be creative! Elicit ideas from clients/staff Step 3: Utilize Behavioral Principles How to monitor behavior Frequency Escalating reinforcers and bonuses Keep schedule simple 22

23 Checklist for Designing CM Programs Step 4: Behavioral Contract Outline target behavior, monitoring system, and reinforcement schedule Be specific and concrete Ex.: Instead of Drug tests will be given 3 times a week, say Drug tests will be given on Mondays, Wednesdays, and Fridays at 8:00am Step 5: Implementation Ensure consistent application of contract Staff needs to work as a team and be consistent Frequent reminders of behaviors/consequences Step 6: Plan for the Future Open communication of what works and what doesn t Make changes to the program as needed Pitfalls Magnitude of incentive is not compatible with behavior demand Target behavior is vaguely defined or understood Ex. Attitude, Showing commitment to recovery are not measurable/observable and can lead to staff biases Target behavior frequently changes Distribution of prizes is inconsistent or infrequent Prizes are undesirable Giving up too soon! Need to monitor progress and make changes Record keeping is poor SABER Tretament Program This sh*t works! Started in 2006 Based on research at UAB Urban Ministry Center-Homeless Coalition in Charlotte, NC Clinical Director: Marilyn Furman, Psy.D., LCAS, CCS Contingency-Based program for men who are homeless 9-month IOP Program (3 months treatment, 6 months Continuing Care) Dual-diagnosis and holistic Funded through grants and donations $550 per month per man Donated housing (CentroBono Foundation), ABC Grants, UMC operational funding 23

24 SABER Treatment Program Requirements Referral only Must be male, homeless (no assets), struggling with addiction, 18 years old and above Must be willing and able to work Not a veteran Not on disability No psychosis Admission of 1-2 clients per week Total of 64 men a year SABER Treatment Program Phase 1 (First 3 months)-day Treatment 5 days a week Full assessment and treatment planning Individual counseling Daily group counseling Psychoeducational groups Recreational Activities (Yoga & YMCA) Abstinence-contingent, rent-free housing Phase 2 (months 3-9)- Continuing Care Abstinence-contingent, rent free housing Job Training and/or education/employment Less structure Extended Continuing Care (if space is available) Reduced rent housing SABER Treatment Program Treatment Goals (long-term and short-term): Addiction Mental Health Housing Recreational (Yoga, YMCA, nutrition) Vocation (Job Training and Computer Training) Includes: Abstinence-contingent, rent-free housing Recreational Activities Job Training $20 Wal-Mart stipend/week Weekly bus pass Group Counseling, Individual Counseling, Psychoeducation, Medical Care Fish Bowl for extra incentive 24

25 SABER Treatment Program Drug Screen/Breathalyzer 3x week Earns housing 4 NA/AA Meetings Earns bus pass Weekly goals/rec Activities Up to $20/week Wal-Mart Stipend Garden Activities Punishments-Natural and Imposed Community support Food through UMC and food stamp program SABER Treatment Program- Community Partners Charlotte Community Health Clinic Yoga One MedAssist YMCA Urban Leage Urban Ministry Center CentroBono Anuvia Detox Program Men s Shelter Now the Stats 89% have served time in jail/prison (Average 4.4 years) Demographics 76% African-American; 19% White; 2% Latino Average age: 44.4 years 42% experienced physical abuse 58% had physical health problems 24% experienced sexual abuse 87% experienced at least one co-occurring mental disorder 51% depressive disorders 37% PTSD 12% Bipolar disorder 68% experienced personality disorder(s) 25

26 Does it work? Economic Benefits Average cost of housing an inmate in Mecklenburg County Jail: $33,952 Jail + treatment = $52,213 SABER + Housing = $5700 per client Decreased recidivism No SABER client has been arrested for committing a crime while in SABER Compare the costs: Detox ($118/night) ER ($1,029/night) Hospital Bed ($2,165/night) SABER ($21/night) Private Practice Example In order to maintain recovery and abstinence from drugs/alcohol in an outpatient setting, the following guidelines have been set into place: If unemployed, client will attend at least one AA/NA meeting each day, as evidenced by signed verification form submitted to counselor each week If unemployed, client will actively search for stable employment, as evidenced by selfreport of job searches/applications/interviews If employed, client will attend at least four (4) NA/AA meetings each week, as evidenced by signed verification form submitted to counselor each week Client will actively seek a 12-step sponsor, as evidenced by Sponsor Log, which will be reviewed each week by counselor and client Client will abstain from all drug and/or alcohol use as evidenced by random drug/ alcohol screenings each month Client will attend individual counseling at least twice a week with counselor for at least one month. After the first month, counselor and client will review client s progress in her recovery and make adjustments, as needed Counselor has the right to refer client to a higher level of care (i.e., IOP, inpatient, detox, PHP, residential treatment) at any point during the client s treatment if it counselor determines that client is not benefitting from individual outpatient treatment. I agree to abide by the contract as indicated above. 26

27 Challenges of CM Cost of incentives Fishbowl method Only use for part of clinic population Target use of specific substances Use with vulnerable clients Calculate maximum cost per client Cost has been shown to be 50% of max On-site testing Monitor other behaviors instead Counselor resistance Why? Challenges of CM Counselor s reactions to CM Enjoyed the flexibility Add-on to existing program approaches Fostered more positive clinical culture Helped client s reach initial abstinence quicker Involve counseling staff in creating the program Challenges to CM Does it work for everyone? The following may contribute to a greater or lesser response to incentive programs (Stitzer et al., 1984): Level of past and present drug use Client s history of success/failure in stopping use of drugs Presence of Antisocial Personality Disorder Nature of client s social networks Client s responsiveness to reinforcements and punishments for behavior change Does this lead to gambling addiction? Study of 800 clients, half received CM treatment Data revealed NO increase in gambling as result of CM 27

28 Challenges Isn t this just rewarding clients for what they should be doing anyway? Challenges How do I select and get the incentives? -Community resources -Donations -Grants Challenges Can Motivational Incentives be used with adolescents, or patients with co-occurring disorders? 28

29 Tips from Experience Be consistent! Observable behaviors More reward, less punishment Fairness Emphasis on earning not giving Natural consequences Be creative! Frequent staff meetings and communication Make it fun and celebratory! Partner with community agencies What do clients say? I felt that I was going down the drain with drug use, that I was going to die soon. This got me connected, got me involved in groups and back into things. Now I m clean and sober. (Kellogg, Burns, et. al. 2005) What do staff say? We came to see that we need to reward people where rewards are few and far between. We use rewards as a clinical tool not as bribery but for recognition. The really profound rewards will come later. (Kellogg, Burns, et. al. 2005) 29

30 What do administrators say? The staff have heard patients say that they had come to realize that there are rewards just in being with each other in group. There are so many traumatized and sexually abused patients who are only told negative things. So, when they heard something good that helps to build their self-esteem and ego. (Kellogg, Burns, et. al. 2005) What do you say? What are your thoughts about Motivational Incentives/Contingency Management? What are your concerns? What are some things you would need to do to consider implementing Motivational Incentives? 30