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Using Motivational Incentives Using Motivational Incentives within Case Management within Case Management
Mark D. Godley, Ph.D.Chestnut Health Systems Bloomington/Normal, IL
35th Annual Meeting of the Alabama Council of Community Mental Health Boards
Birmingham, ALMay 14, 2009
This work is supported by grants from the National Institute on Alcoholism & Alcohol Abuse, National Institute on Drug Abuse, and the SAMHSA’s Center for Substance Abuse Treatment. The opinions are those of the author and do not reflect official positions of the government.
PurposePurpose
Describe how contingency management (CM) or motivational incentives work
Vouchers vs. On-site Prizes Describe how CM can be implemented within a
community based continuing care program following residential treatment
Review the effectiveness of CM Discuss recommendations to improve
effectiveness of CM
How does it work?How does it work?
Contingency Management or Motivational Incentives: Relies on close temporal association between the
behavior to be increased followed by the reward. The contingency between the behavior and the
reward is what changes behavior—not the reward alone.
Choice of reward is important to sustain behavior change
Rewards emphasize accomplishment and set postive expectation
Petry & Stitzer (2003)
Contingency Management in Contingency Management in Treatment of Substance Use Treatment of Substance Use DisordersDisorders
Increase behaviors consistent with recovery such as: Schedule activities when adolescents might use Exposure to non-using peers Develop new or rekindle interest in pro-social
activities Participation in treatment, 12-step meetings Activities with caregivers and family
Many studies with adults Few studies with adolescents
CM ProceduresCM Procedures
Case manager met with adolescent at least once a week for 12 weeks post-discharge
Breathalyzer test, urine screen administered/immediately tested
Verification for the activities completed in the prior week and choose activities to complete in the next week Leisure questionnaire from Petry et al.
Not rewarded for attendance, but if no-show, missed opportunity to draw for prizes
Earned draws for verified completed activities and for providing negative breath and/or urine samples
CM ProceduresCM Procedures
Drew labeled slips of paper from fishbowl, potential to win a prize
510 slips in fish bowl Types of draws: Smiley faces (30%), small
(62.8%), large (7%), or jumbo prizes (0.2%)
Draw Schedule for Clean UA Draw Schedule for Clean UA ScreensScreens
Draw Schedule for ActivitiesDraw Schedule for Activities
PrizesPrizes
Smiley face = no prize won Small = $1 prize (i.e., candy, snacks, soda,
toiletries) Large = $25 prize (i.e., camera, CD player, gift
certificates, perfume) Jumbo = $100 prize (i.e., gift certificates, DVD
player, television, video game console) Chose prize from prize catalog and/or prize
bag
Examples of Pro-Social Examples of Pro-Social ActivitiesActivities
Education Obtain information about classes, register, do
homework Employment
Obtain job applications, submit applications, job interviews
Family/friends Visit with family/non-using friends, attend
parenting class Health
Attend therapy, attend doctor’s appointments
Examples of Pro-Social Examples of Pro-Social ActivitiesActivities
Legal See probation officer, community service,
court dates Personal improvement
Haircut, other salon services Sobriety
Attend outpatient, 12-step meeting Social/recreational/household
Music, reading, exercise, painting, church, chores
Other
Four Randomized ConditionsFour Randomized Conditions
Usual Continuing Care (UCC)
UCC + Assertive Continuing Care
(ACC)No Contingency Management (No CM)
Contingency Management (CM)
No CM
UCC
No CM
UCC + ACC
CM
UCC
CM
UCC + ACC
Participant CharacteristicsParticipant Characteristics
Mostly male (65%), Caucasian (64%) and 15 to 16-years-old (59%)
Lifetime cannabis dependence (67%) Symptoms of internalizing disorders (58%) Symptoms of externalizing disorders (71%) Completed residential treatment as planned
(56%) Left treatment against staff advice (29%) Left treatment at staff request (15%)
Usual Continuing Care (UCC)Usual Continuing Care (UCC)
Refer back to treatment provider in home community
About 56% received continuing care Type of services vary but tend to be outpatient
or IOP
Assertive Continuing Care (ACC)Assertive Continuing Care (ACC)
Seven days or longer in treatment Uses home visits Sessions for adolescent, caregiver(s), and
both 12-14 sessions based on A-CRA manual
(Godley, Meyers et al., 2001) Case Management based on ACC manual
(Godley et al., 2006)
CM Results: Pro-Social ActivitiesCM Results: Pro-Social Activities
97% completed one or more selected activity Mean activities selected = 20 Mean activities completed = 13 1,739 activities chosen; 1,114 (64%)
completed 98% chose social/recreational activities
Completed 64% of the time
CM Results: Pro-Social ActivitiesCM Results: Pro-Social Activities
78% chose sobriety activities 52% of participants chose to attend at least
one 12-step meeting; completed 58% of the time
50% of participants chose to attend outpatient treatment, completed 62% of the time
39% chose education, family/friends, legal, and household activities
Completion rates ranged from 56% for personal improvement to 73% for household-related activities
CM Results: Consecutive Clean CM Results: Consecutive Clean Urine ScreensUrine Screens
ACC + CM 53% abstinent for 4+ weeks 33% abstinent for 8+ weeks 16% abstinent for 12-14 weeks (negative
screens for entire continuing care period) UCC + CM
58% abstinent for 4+ weeks 38% abstinent for 8+ weeks 15% abstinent for 12-14 weeks (negative
screens for entire continuing care period)
Treatment Outcomes for AOD Treatment Outcomes for AOD UseUse
25%
35%
28%
30%
0%
5%
10%
15%
20%
25%
30%
35%
40%
UCC (n=84) CTM (n=84) ACC (n=79) ACC+CTM (n=88)
Incre
ase
in
% D
ays A
bstin
en
t
Stability of Outcomes for AOD Stability of Outcomes for AOD UseUse
-19%
-3%
3%
-12%
-25%
-20%
-15%
-10%
-5%
0%
5%
10%
15%
20%
25%
UCC (n=84) CTM (n=84) ACC (n=79) ACC+CTM (n=88)
Incre
ase
in
% D
ays A
bstin
en
t
Percent of Days Abstinent from Percent of Days Abstinent from AOD UseAOD Use
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
Intake 3 6 9 12
Wave
UCC (n=79) CTM (n=73) ACC (n=73) ACC+CTM (n=82)
Percent of Days Abstinent from Percent of Days Abstinent from Heavy Alcohol Use, while in the Heavy Alcohol Use, while in the CommunityCommunity
60%
65%
70%
75%
80%
85%
90%
0 3 6 9 12
Wave
1.00 UCC only 2.00 UCC w/ CTM 3.00 ACC only 4.00 ACC w/ CTM
ConclusionsConclusions
It is possible to implement motivational incentives for adolescents with severe problems to increase pro-social activities and clean urine screens.
The program can be implemented through a home visiting case management approach or in the office
Cost of incentives was under $100.00 Motivational Incentives worked but did
not have the long term effectiveness of ACC
RecommendationsRecommendations
Specifically contract for activities that compete with high-risk using times of the week. Use A-CRA Functional Analysis of Substance Use
Identify possible behaviors that would be incompatible with substance use Use A-CRA Functional Analysis of Pro-Social
Behavior Leisure Questionnaire used in A-CRA
Increase effectiveness of motivational incentives: Increase prize values Improve odds of drawing large prizes Increase frequency of prize drawings
For More InformationFor More Information
Mark GodleyChestnut Health Systems
448 Wylie DriveNormal, IL 61761
Godley, S.H., Godley, M.D., Wright, K.L., Funk, R.R., & Petry, N.M. (2008). Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care. American Journal on Addictions, 17 (4), 278-286.