Peter Coleman, M.S., CASAC Marylee Burns, M.Ed., M.A., CRC Scott Kellogg, Ph.D.

Peter Coleman, M.S., CASAC Marylee Burns, M.Ed., M.A.,

CRC Scott Kellogg, Ph.D.

CONTINGENCY MANAGEMENT APPROACH:

IMPLEMENTATION AND OUTCOMES

22

Workshop Outline

Overview of NYC Health and Hospitals Overview of NYC Health and Hospitals and the Foundations of Changeand the Foundations of Change

The Latest Research on Contingency The Latest Research on Contingency Management Management

The HHC Experience: Implementation The HHC Experience: Implementation and Outcomesand Outcomes

33

Overview of NYC Health and Hospitals

Corporation and the Foundations of Change

44

NYC Health and Hospitals Corporation (HHC)

Largest municipal Largest municipal health care provider health care provider in United Statesin United States

Provides services to Provides services to 1.3 million NYC 1.3 million NYC residents residents

Offers full array of Offers full array of health, mental health, mental health, and chemical health, and chemical dependency servicesdependency services

8 Inpatient Detox Units8 Inpatient Detox Units 8 Methadone Treatment 8 Methadone Treatment

ProgramsPrograms 19 Outpatient Chemical 19 Outpatient Chemical

Dependency ProgramsDependency Programs 2 Halfway Houses2 Halfway Houses 4 Hospital Intervention 4 Hospital Intervention

Programs, and Programs, and Case Management Case Management

ProgramProgram

Contingency Management

Why Should We Change Anything?

We’ve been providing drug treatment for years and our patients do fine!

66

Addiction is a major public health issue – providing

effective treatment a major challenge

It is estimated that only 20% of those It is estimated that only 20% of those addicted to opiates are engaged in addicted to opiates are engaged in treatment.treatment.

50% of non-funded MTP programs in NYS 50% of non-funded MTP programs in NYS report that fewer than 54% of those entering report that fewer than 54% of those entering treatment are retained for more than 1 year. treatment are retained for more than 1 year.

50% of non-funded MTP programs in NYS 50% of non-funded MTP programs in NYS report that less than 32% of patients report that less than 32% of patients discharged have discontinued use of heroin. discharged have discontinued use of heroin.

77

Addiction May be Considered a Medical Condition, but…

It is often viewed as a moral weakness that is It is often viewed as a moral weakness that is self inflicted and best dealt with through the self inflicted and best dealt with through the criminal justice system.criminal justice system.

While it is a chronic disorder, it is often While it is a chronic disorder, it is often treated as an acute condition with treated as an acute condition with expectations of immediate resolution.expectations of immediate resolution.

Patients are often stigmatized by society, Patients are often stigmatized by society, medical providers and treatment program medical providers and treatment program staff, and by family, friends and peers.staff, and by family, friends and peers.

88

External Pressures for Change

Increased focus on program accountability, Increased focus on program accountability, measurement of progress and clinical measurement of progress and clinical outcomesoutcomes

Welfare reform and related financial Welfare reform and related financial ramificationsramifications

Demand for individualized treatment, Demand for individualized treatment, respectful of patient rightsrespectful of patient rights

CSAT program accreditation requirementsCSAT program accreditation requirements

99

The Truth About Change

Change typically requires a systems approach Change is not easy and is a long-term process Change requires a vision and commitment on

behalf of the entire organization Change involves trial and error as well as

ongoing evaluation Change requires strong leadership, but it is

best accomplished when done with input and participation of patients and staff

1010

Foundations of Change at HHC

1998 OASAS Vocational Initiative

1999 mayoral scrutiny of methadone treatment

2000 OASAS/HRA Vocational Initiative

2001 New CSAT 2001 New CSAT regulations for opioid regulations for opioid treatmenttreatment

Desire to incorporateself sufficiency and employment as major treatment goals

Conscious decision toimprove quality of care,patient satisfaction, andtreatment outcomes

1111

Initial Actions and ResultsInitial Actions and ResultsInitial Actions:Initial Actions:

Vocational Rehab staff Vocational Rehab staff added and Career added and Career Centers establishedCenters established

MTP WorkgroupMTP Workgroupestablishedestablished

Practice Guidelines Practice Guidelines and Manuals and Manuals developeddeveloped

Reporting mechanisms Reporting mechanisms put in placeput in place

Initial Results:Initial Results: Nature of clinics Nature of clinics

changed but culture changed but culture didn’tdidn’t

Treatment approach had Treatment approach had punitive feelpunitive feel

Patients did not respond Patients did not respond and retention declinedand retention declined

Staff disenchantedStaff disenchanted Improvements Improvements

unsustainedunsustained

1212

Reinvigorating the Process Workgroups

expanded and continued to meet

Administrative support increased

Staff polled regarding attitudes and needs

Patient satisfaction surveys undertaken

Training Initiatives:– “Thinking Outside

the Box”– Transtheoretical

Modelof Behavioral Change

– Project Invest– Management

Training: “Successfully Supervising People”

Moving in the Right Direction:- Leadership invigorated- Staff attitudes improved- Treatment began to shift away from punitive policies- Improved therapeutic environment

But patient outcomes, particularly in But patient outcomes, particularly in relation to self sufficiency and relation to self sufficiency and

employment, had still not improved employment, had still not improved to desired levelsto desired levels

1414

Patient Motivation and Recognition Initiative

Based on research which supported use of tokens to encourage and motivate patients towards treatment goals

Used recognition of patient achievements as mechanism for improving self image and peer support

Focused on advancement in treatment and attainment of goals as well as vocational issues

1515

Programs were required to submit

a plan that included: Specific, measurable

objective benchmarks Description of

motivational supports Description of patient

recognition activities Timeline for

implementation and integration

Mechanism for staff training and patient education

Proposed methods for supplemental and ongoing support

Method of tracking outcomes and accounting for supports

9 programs responded and were ultimately awarded an

average of $12,900 each plus a supply of Metrocards and gift

certificates

Contingency Management was on it’s way!

1717

Science Meets Practice

As an outgrowth of a Contingency Management Panel (Kellogg and Stitzer) presented at the NIDA Blending Conference held in New York in March, 2002

As a direct result of the Blending Conference, a collaboration developed between Ms. Marylee Burns and Mr. Peter Coleman of the Office of Behavioral Health of the New York City Health and Hospitals Corporation (HHC), and Scott Kellogg, PhD of The Rockefeller University and the CTN.

1818

The Collaboration

Staff were provided with papers by Drs. Stitzer, Staff were provided with papers by Drs. Stitzer, Petry, and HigginsPetry, and Higgins

Dr. Kellogg presented research on contingency Dr. Kellogg presented research on contingency management to Substance Abuse Directors management to Substance Abuse Directors MeetingMeeting

Ms. Burns and Dr. Kellogg went to participating Ms. Burns and Dr. Kellogg went to participating programs to meet with staff, speak about the programs to meet with staff, speak about the research, and critique the initial efforts to research, and critique the initial efforts to develop Contingency Management components develop Contingency Management components within the programswithin the programs

1919

Where are we in 2004? 8 of the original 9 programs (6 MTPs and 2

O/P) were allocated additional funds which averaged $19,166

5 additional O/P programs were allocated funds which averaged $10,000

Additional training resources were provided

Day-long Contingency Management Conference: Science in the Trenches

Successful implementation of Contingency Management

at HHC reflects the sum of the various parts

2121

Setting the Stage:Factors In Success

Commitment of the system to long term process for treatment improvement

Availability of initial funding and potential for additional funds

The adoption of science for the clinical paradigm and framework

Leadership direction and oversight

2222

Teamwork between program leadership and line staff which empowered staff and encouraged creativity

Patient participation, recognition, enthusiasm and empowerment

Therapeutic environment which focused on positives and moved from sanctions to rewards

Individualization of care; particularly the matching of patient treatment needs to motivations

2323

Ongoing process of review, revision and Ongoing process of review, revision and improvementimprovement

Integration of contingency management into Integration of contingency management into overall structure of treatment approachoverall structure of treatment approach

Staff training initiativesStaff training initiatives

Networking and collaborating with NIDA CTN Networking and collaborating with NIDA CTN affiliated researchersaffiliated researchers

2424

Research on Research on Contingency Management Contingency Management Approaches in Substance Approaches in Substance

Abuse SettingsAbuse Settings

2525

Contingency Management An approach that has been in use since the late 1970’s Developed by Dr. Maxine Stitzer at Johns Hopkins

University Further developed by Dr. Stephen Higgins at the

University of Vermont, by Dr. Nancy Petry at the University of Connecticut, and by Dr. Ken Silverman at Johns Hopkins University

Based on the work of B. F. Skinner Behavior is determined by its consequences Reinforcement -- Increases the likelihood of a behavior

occurring Punishment -- Decreases the likelihood of a behavior

occurring

2626

THE FANTASYTHE FANTASY

Patients Recognize that they have a Problem They Know they Need Help with that Problem

They come to treatment ready for change

2727

REALITY CHECK…….

What REALLYmakes patients

come to treatment?

2828

Negative Consequences of Drug Use

Treatment

2929

Family MembersEmployersParole/ProbationChild Protective Services

External Negative Consequences

3030

Personal Negative Consequences

Many Patients Come toTreatment Because

BAD Things are Happening,Others are Angry with Them,

They are Tired and Depressed,

They have run out of money, They Want Life to Change

BUT……...

3131

Drugs are Drugs are Positive Reinforcers

They Make They Make People People Feel Good.Feel Good.

3232

Drug Abusers Straddle Drug Abusers Straddle the Fencethe Fence

3333

Behavioral Results of AmbivalenceBehavioral Results of Ambivalence

Some patientsdrop out oftreatmentearly

Some patientscontinue touse drugs duringtreatment

Some patients stop using

Continued

Drug Use

DrugAbstinence

MethodsMethods are needed are needed to:to:

- - counteract ambivalencecounteract ambivalence- increase motivation for - increase motivation for changechange

3535

What are Motivational What are Motivational Incentives and How Can Incentives and How Can

They HelpThey Help

3636

Motivational Incentives In Motivational Incentives In Everyday LifeEveryday Life Child rearingChild rearing

Praise and disciplinePraise and discipline Education Education

Grades/honors and Grades/honors and detention/suspensiondetention/suspension

Business Business organizationsorganizations

Bonuses; promotions and Bonuses; promotions and sanctions/demotionssanctions/demotions

Criminal justiceCriminal justice Arrest/incarceration and Arrest/incarceration and

early release early release

3737

Examples of Rewards

Attention, Pat on the Back Prizes and

Gifts

Vouchers and Gift

Certificates

Privileges

Services

3838

Examples of Punishers

Fines Tickets Restriction

s Sanctions Displeasur

e

3939

It is the CONTINGENCY that matters……….

BEHAVIOR

REWARD

•Giving things away for free does NOT change behavior•The closer in time, the more powerful the reinforcement

4040

PunishmentsPunishments

Do not teach what to do; only what not to doDo not teach what to do; only what not to do

Promote harsh and demeaning atmospherePromote harsh and demeaning atmosphere

May also do harm (e.g. promote aggression)May also do harm (e.g. promote aggression)

Are necessary under limited circumstancesAre necessary under limited circumstances

4141

RewardsRewards

Teach new behaviors and promote growthTeach new behaviors and promote growth

Promote positive atmosphere & communication Promote positive atmosphere & communication

Promote self-esteem and self-confidencePromote self-esteem and self-confidence

Sustainable over timeSustainable over time

4242

Rewards versus Punishments

Which is used more frequently?

4343

Punishments!Punishments!

4444

Application to Drug Application to Drug Abuse:Abuse:

Intervention TargetsIntervention Targets Improved Therapy AttendanceImproved Therapy Attendance Decreased Drug UseDecreased Drug Use Treatment Plan Goal AttainmentTreatment Plan Goal Attainment

4545

Common Naturally Occurring Common Naturally Occurring Rewards Rewards

and Punishers In and Punishers In Drug Abuse TreatmentDrug Abuse Treatment

PositivePositive NegativeNegative- take-homes- take-homes - time restriction- time restriction- award ceremonies- award ceremonies - missed services- missed services- certificates; key chains- certificates; key chains - probation- probation- status/recognition- status/recognition - dismissal- dismissal

4646

Motivational Incentives Research

Clients earn vouchers for drug-free urinesClients earn vouchers for drug-free urines– usually cocaine-free urinesusually cocaine-free urines

Vouchers are worth moneyVouchers are worth money Vouchers are exchanged forVouchers are exchanged for

– retail items (e.g. clothing, sports retail items (e.g. clothing, sports equipment)equipment)

– services (e.g. rent; bill payments)services (e.g. rent; bill payments)

4747

Research on Research on Motivational IncentivesMotivational Incentives

Cocaine abusers in drug-free treatment Cocaine abusers in methadone treatment

4848

Treatment of Cocaine Dependence in a Drug-Free Clinic

Higgins et al., 1994

Control TreatmentCommunity Reinforcement Approach TherapyUrine testing 2x/weekNo vouchers

$10

Incentive TreatmentCommunity Reinforcement Approach TherapyUrine testing 2x/weekVouchers

Can earn over $1000Actual earnings: 600

4949

0

25

50

75

100

%

Incentive Standard

0

25

50

75

100

%

Incentive Standard

>8 Weeks of Cocaine AbstinenceRetained Through

6 month Study

Higgins et al., 1994

Treatment of Cocaine Dependence

5050

One-year Follow-up Results

• 60% of incentive group were cocaine abstinent

• While 45% of the control group were abstinent

• During-treatment abstinence predicts long-term abstinence

5151

Treatment of Cocaine Abuse Treatment of Cocaine Abuse in Methadone Patientsin Methadone Patients

Silverman et al., 1996Silverman et al., 1996

Contingent Incentives 3x weekly urine

testing received vouchers

only if urine samples were cocaine negative

Up to $1155 available Average earnings of

$426

Non-Contingent Incentives

3x weekly urine testing

received vouchers regardless of urine test results

5252

0

25

50

75

100

%

Incentives Standard0

25

50

75

100

%

Incentives Standard

>8 Weeks of Cocaine Abstinence

Retained Through Study

Treatment of Cocaine Use in Methadone Patients

Silverman et al., 1996

5353

0

1

2

Incentives Standard

0

25

50

75

100

%

Incentives Standard

Used willpower to reduce cocaine use

Overall helpfulness oftreatment

Patient Ratings of Helpfulness

Silverman et al., 1996

5454

Adaptation into Adaptation into Standard Clinic SettingsStandard Clinic Settings

Intermittent reward for good behavior reduces cost

5555

Intermittent Incentive Study with Alcoholic-Dependent Outpatients

Subjects: alcohol-dependent outpatientsStandard treatment:

•Intensive outpatient day program •5 hrs/day, 5 days/week, weeks 1-4

•Aftercare •1-3 groups/week, weeks 4-8

Treatment consisted of group sessions: 12 step, relapse prevention, vocational rehab, AIDS, coping skills

5656

Intermittent RewardIntermittent Reward Instead of getting reinforced every time

they are drug-free, The drug-free patient draws from the

“fishbowl” 50% of the draws are verbal

reinforcements that say “good job” And 50% of draws are “winners”

5757

Control GroupControl Group

Received standard group treatment and Received standard group treatment and Breath Alcohol (BAC) monitoring Breath Alcohol (BAC) monitoring (daily during intensive, weekly during (daily during intensive, weekly during

aftercare).aftercare).

Additional 15 min ofAdditional 15 min ofeducation oneducation onalcohol abuse weeklyalcohol abuse weekly

5858

Incentives Group

Standard group treatment and BAC monitoring

Incentives for alcohol abstinence:– One draw for each negative BAC.– Five bonus draws for a week of

consecutive abstinence.

5959

42% of the cards are worth a small prize (i.e. toiletries, food)

7% are worth a medium prize (i.e., cordless phone, CD)

And less than 1% are worth a jumbo prize (i.e., TV, video)

Half the cards are winning

6060

RetentionRetention

0

20

40

60

80

100

2 4 6 8

Weeks

StandardIncentives

Petry et al., 2000

% R

etai

ned

6161

Time Until First Drinking Episode

0

20

40

60

80

100

2 4 6 8

StandardIncentives

Petry et al., 2000

% A

bstin

ent

Weeks

6262

Percent Positive for Percent Positive for Any Illicit DrugAny Illicit Drug

0

10

20

30

40

50

%

Intake Week 4 Week 8

StandardIncentives

Petry et al., 2000

6363

Summary of ResearchSummary of Research This intermittent schedule of This intermittent schedule of

incentives significantly increased incentives significantly increased retention and reduced alcohol, as well retention and reduced alcohol, as well as other drug, use.as other drug, use.

On average, subjects earned $200 On average, subjects earned $200 worth of prizes.worth of prizes.

Local retailers and stores were willing Local retailers and stores were willing to donate prizes.to donate prizes.

6464

The Original PlanThe Original Plan When I first became a part of this project, When I first became a part of this project,

each HHC clinic was expected to create a each HHC clinic was expected to create a plan for distributing reinforcements in an plan for distributing reinforcements in an appropriate and systematic way to their appropriate and systematic way to their patientspatients

The idea was that when patients reached The idea was that when patients reached various benchmarks, they would receive a various benchmarks, they would receive a prize or reward (i.e., a gift certificate)prize or reward (i.e., a gift certificate)

6565

Potential Shortcomings After our dialogue about CM, it became clear After our dialogue about CM, it became clear

that there might be a shortcoming to this that there might be a shortcoming to this planplan

My thought was that they were creating a “reward” program rather than a “reinforcement” program

6666

Reward Vs. Reinforcement The “reward” program can be seen as one

that is set up to acknowledge major accomplishments – maintaining abstinence for 1 month; holding a job for 3 or 6 months; or completing a one-year program; in a sense, it is a program to reward “virtue”

The greatest concern was that it would The greatest concern was that it would result in the distribution of prizes to the result in the distribution of prizes to the “best” or “most successful” patients“best” or “most successful” patients

While having little or no impact on those While having little or no impact on those who were having serious problems attaining who were having serious problems attaining or maintaining abstinence and sobrietyor maintaining abstinence and sobriety

6767

Reinforcement ProgramsContingency management programs have

the ability to:

Reinforce each of the steps and each of the components that are involved in reaching the goal, not just the attainment of the goal

Be more gradualistic, and, while not value-free, they are not as overtly value-oriented

Focus more on initiating and maintaining behavior change

Allow us to go from “You have done a good job” to “You have taken a step in the right direction”

Help not only the most motivated patients, but also those who are more troubled and/or more severely addicted have the opportunity to benefit (Petry et al., 2001)

6868

Definitions and Constructs

Technically, “reward” and “reinforcement”, Technically, “reward” and “reinforcement”, as used here, are the same thing; the issue is as used here, are the same thing; the issue is the criteria for reinforcement (Kazdin, 1994; the criteria for reinforcement (Kazdin, 1994; Wolpe, 1982)Wolpe, 1982)

However, clinically, the social constructs of However, clinically, the social constructs of “reward” and reinforcement” were quite “reward” and reinforcement” were quite meaningful to the staff and the leadershipmeaningful to the staff and the leadership

6969

Definitions and Constructs (2) Giving things to people on the way Giving things to people on the way

to accomplishing a goal seemed to accomplishing a goal seemed fundamentally different from giving fundamentally different from giving to them only when they achieved itto them only when they achieved it

It was this difference that played a It was this difference that played a crucial role in reorienting the HHC crucial role in reorienting the HHC clinics and making this project a clinics and making this project a successsuccess

7070

Reinforcement StrategiesA number of guidelines about the use of contingencies were emphasized (see also

Kirby et al., 1999):

1.1. Reinforcements should be given very frequently Reinforcements should be given very frequently

2. It should be very easy to earn reinforcements at 2. It should be very easy to earn reinforcements at the start; the “bar” should be kept lowthe start; the “bar” should be kept low

3. An example of this is that when the trainers at 3. An example of this is that when the trainers at Sea World begin to teach the whales to jump Sea World begin to teach the whales to jump over the hoops, they start with the hoop being over the hoops, they start with the hoop being under the water; the whales are reinforced for under the water; the whales are reinforced for simply swimming over it (Coonradt, 1996)simply swimming over it (Coonradt, 1996)

7171

Reinforcement Strategies Reinforcement Strategies (2)(2)

4. To be as effective as possible, the reinforcements should 4. To be as effective as possible, the reinforcements should include material goods and services and these need to be of include material goods and services and these need to be of use and value to the patientsuse and value to the patients

5. Social reinforcement alone is not likely to be sufficient -- 5. Social reinforcement alone is not likely to be sufficient -- especially for patients who are disconnected or socially especially for patients who are disconnected or socially phobicphobic

6. Reinforcements will be most effective if their distribution 6. Reinforcements will be most effective if their distribution is connected to specific and observable behaviors and they is connected to specific and observable behaviors and they receive them immediately after exhibiting the behavior (i.e., receive them immediately after exhibiting the behavior (i.e., attending the group)attending the group)

7. The greater the delay in receiving the reinforcement, the 7. The greater the delay in receiving the reinforcement, the weaker its effect is likely to beweaker its effect is likely to be

7272

Clinical Considerations

Emphasize the positive Focus on the good things the patients did --

not their failings Any steps in the right direction is a cause for

celebration In the face of setbacks, patients should be

encouraged, not criticized Reinforcement criteria should be clear to

both the patients and the staff; if they meet the criteria, they must receive the reinforcement -- regardless of their drug use status

7373

Social AspectsSocial Aspects

There are powerful social reinforcement processes at work when the counselor gives the reinforcement to the patient

Counselors who are not enthusiastic might inadvertently have a damaging impact on its efficacy

A congratulatory approach is seen as the most appropriate one

7474

Implications for CounselingImplications for Counseling

It was emphasized that CM is not a substitute for counseling

Reinforcements do not directly teach people how to abstain nor do they provide skills -- they simply strengthen behaviors that lead to that outcome

Counselors have a valuable therapeutic Counselors have a valuable therapeutic opportunity to explore with their patients what opportunity to explore with their patients what actions they took to avoid using drugs; this can actions they took to avoid using drugs; this can be used to develop future coping strategies be used to develop future coping strategies (Morral, Iguchi, & Belding, 1999)(Morral, Iguchi, & Belding, 1999)

7575

The HHC Experience:

Implementation and Outcomes

7676

Implementation

7 out of 9 clinics implemented programs7 out of 9 clinics implemented programs

Contingency management programs varied – Contingency management programs varied – some used points/tickets, others the fishbowlsome used points/tickets, others the fishbowl

Many plans changed along the wayMany plans changed along the way

Group attendance as well as goal attainment Group attendance as well as goal attainment were reinforced - material and social were reinforced - material and social reinforcements were usedreinforcements were used

7777

Implementation - continued

Reinforcements were distributed in both group and individual settings.

Programs expanded upon existing award ceremonies.

7878

Benchmarks & Reinforcements

Benchmarks included: Group attendance Goal attainment* Negative toxicologies Completion of medical and psychosocial

history

*Higher levels of reinforcement were used for groups that involved exploring careers, education and other work related issues.

7979

Range of prizes – some matched with program issues e.g. job interview

McDonald’s coupons, movie passes, transportation vouchers (“metro cards”), calendars, gift certificates from major department stores and music outlets, date books, tools, clothes, books, tee-shirts, microwaves, water bottles, sunglasses, things for children, toiletries, food, and candy

Reinforcements:

8080

8181

8282

8383

8484

8585

8686

8787

Implementation Process

At first, there was a fair amount of staff At first, there was a fair amount of staff resistance…resistance…

“ “This was a long and hard process and there This was a long and hard process and there were lots of fights. Staff saw it as a negative were lots of fights. Staff saw it as a negative at first…,. As the director, I allowed the staff at first…,. As the director, I allowed the staff to ventilate. The Vocational staff started the to ventilate. The Vocational staff started the whole process because their orientation is whole process because their orientation is far more receptive to this kind of thing.” far more receptive to this kind of thing.” (Program Director)(Program Director)

8888

Patients Reactions

Some patients needed tangible evidence of such prizes

Eventually patients were very enthusiastic

Their self esteem seemed to increase as seen in their improved appearance and their attendance to and interest in groups.

They also began to become more empowered as seen in their development of goals

8989

Clients were saying…”In Russia, we were forced into treatment -- Now (crying), my God, I’m getting treatment and $25.00!”

“Clients are proud and are having fun. Early in treatment, when their name is called out, they are feeling good that they are being acknowledged. For once in their life, they are being rewarded for something.”

“When the client signs onto the computer, they see ‘Dust-off Your Dreams – Treatment Works’. We know that clients’ dreams were lost to drug addiction. Now, clients are able to go to Macy’s and J.C. Penney. This is big time for them; they’re able to shop at prestigious stores.”

Patients Reactions - Continued

9090

A core issue here was the profound emotional and economic deprivation that these patients had experienced and continued to experience.

The reinforcements and awards were so powerful because some patients believed that the staff did not care about them, and others, in their 30’s and 40’s, had never received a certificate for anything.

Because of their high levels of economic deprivation, the gift certificates frequently made a significant difference in their lives.

Patients Reactions - continued

9191

The basic process was that the reinforcements got them to the groups and motivated them to stay, and then the power of the group began to have its impact.

As has been noted elsewhere (Petry et al.,

2001), patients first came for external reasons and then chose to stay because of their internal motivations.


9292

Patients who participated in the program Patients who participated in the program often began to become more socially often began to become more socially integrated and began to socialize with each integrated and began to socialize with each otherother

– They would use their coupons and go to They would use their coupons and go to movies together in groupsmovies together in groups

– There were also reports that they were There were also reports that they were taking care of each other and giving each taking care of each other and giving each other giftsother gifts


9393

Their sense of connection to the program grew and they participated more freely in its events… “The staff heard clients say that they came 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 hear something good – that helps to build their self-esteem and ego. As one patient put it, ‘I used to think the drug dealer cared for me but this is really caring.’” (Counselor)

In many cases, the prizes became a vehicle for family healing


9494

Patient Reactions - Internalization

They developed increased sense of ownership and responsibility for their program and their recovery.

– “You are forcing me” to “I choose.”– “In one striking example, patients who felt that

methadone initially made them drowsy, delayed the taking of their medication until after their group so they could be more alert and alive..”

– Clients also began to speak privately to their counselors about individuals who were dealing drugs or otherwise engaging in anti-therapeutic behavior.

9595

Counselor Experiences

Morale improved – Identification with evidence-based practice:

“It gives me a great deal of pleasure to know I’m part of a state-of-the-art methadone treatment program.”

– Public gratitude -“In the last two award ceremonies, clients said, ‘I want to thank the staff….’ That sounded real good – we feel appreciated.”

9696

Communication Improved – Staff designed, evaluated and changed CM

programs– Staff spoke more of patient changes and made

more team decisions regarding treatment

Staff Attitude Improved– “I love coming to work now.”

Counselor Experiences - continued

9797

Relationships among the different staff services improved…

“Last year, the staff were not positive. They were very territorial, and somebody was always waiting to attack this idea. Perhaps they were feeling very threatened… Now, the staff are more cohesive.”

(Program Director)


9898


“There has been a major acceptance now for vocational counseling and activities, and we now have a “Wall of Fame.” [A bulletin board with pictures of employed patients.] Before, the rehabiliation counselors were the brunt of sarcasm, now clients are asking that their pictures could be added to the board.”

9999

Perception of the use of reinforcements began to change. “We came to see that we need to reward people

where rewards in their lives were few and far between. We use the rewards as a clinical tool – not as bribery, but for recognition. The really profound rewards will come later.”

Even small steps were recognized and celebrated. “I felt resistant at first…. But, as it caught on, I

began to like giving points to clients. I saw that my client wasn’t using dope, only coke, and I’d say – give him a point! So, now I’m very involved.”


100100

Kings County HospitalVocational Outcome Data

Kings County did a comparison between a group of patients who were enrolled in a series of vocational groups and received incentives and another group of patients that were involved with the vocational groups before the incentives were introduced.

25% of the non-incentive group (n = 20) completed the series while 61% of the incentive group (n = 18) completed the series of groups.

101101

Before C.M. After C.M. N = 20 N = 18

# of Clients Completed Five 2-Hour Vocational Workshops

5 (25%)

11 (61%)

# of Clients in Training1 (5%)

3 (17%)

# of Clients in School/GED2

(10%)4

(22%)

Total # of Clients Vocationally Engaged

8 (40%)

16 (89%)

The two groups were compared at a six-month follow-up. 40% of the non-incentive group were vocationally engaged while 89% of the incentive group were vocationally engaged.

102102

Before C.M. After C.M. (Census stable at 350) as of 12/02 as of 4/03 # of Clients Employed 102 120 # of Clients in Training 7 15# of Clients in WEP 11 29# of Vocational Service Visits (group & individual) 60 172Pay Stubs and Documentation of Employment Submissions 40 95

Harlem Hospital Vocational Outcome Data

103103

Clinic Changes - Mood and Culture

Marked decrease in conflicts and disruptive behavior in some of the clinics…

“The mood has changed in the last 6 months – there has been less disciplinary action – in fact, no fights at all. There has been no need for escorting people out of the building as has been the case in the past.”

“Before, the clients would yell and curse, and now things are calm. Amazing.” “Clients are more pleasant – it’s an easier place to exist in.”

104104

Clinic Changes - Mood and Culture

““I think it does strengthen the alliance with the team, not just one counselor. The program has become nurturing.”

Communication Improved Staff spoke more of patient changes and made

more team decisions regarding treatment.Staff designed, evaluated and changed CM

programs.

Staff Attitude Improved“I love coming to work now.”

105105

Staff, Patient, and Clinic Overall Impressions

One year later, the contingency management programs were a reported success and valued by both staff and patients.

The patients loved it, and some reported that it had saved their lives. They felt that their drug use had been getting worse and worse, and it was the contingencies that encouraged their choosing a different life direction.

106106

Staff, Patient, and Clinic Overall Impressions - continued

The staff and leadership were very excited about and proud of their reinforcement programs. As one counselor put it,

“I don’t know who invented it, but it was a stroke of genius.”

107107

Acknowledgements

108108

Collaborators of this project were: Marylee Burns, MEd, MA, CRC, Assistant

Director, HHC Office of Behavioral Health Peter Coleman, MS, CASAC, Senior

Director, HHC, Office of Behavioral Health

Scott Kellogg, Ph.D., Clinical Psychologist, Laboratory of the Biology of the Addictive Diseases, The Rockefeller University

109109

Development, implementation and support of Development, implementation and support of this project is due to the efforts of the this project is due to the efforts of the leadership, staff, and patients of the New York leadership, staff, and patients of the New York City HHC Chemical Dependency Programs. City HHC Chemical Dependency Programs.

We’d like to thank specifically…We’d like to thank specifically…

HHC’s Office of Behavioral Health:HHC’s Office of Behavioral Health:

Joyce B. Wale, Senior Assistant Vice President Michael Norman Haynes, Sr. Management

Consultant, and Antonio Webb, Sr. Management Consultant

110110

Ludwig Hauser, CSW and the staff of Bellevue Hospital’s Methadone Treatment Program,Jaime Rosario, CSW and the staff of Coney Island Hospital’s Outpatient Chemical Dependency Treatment Program, Martin Gaffney, CSW and the staff of Elmhurst Hospital’s Methadone Treatment Program,Aisha Muhammad, CSW and Curtis Saunders and the staff Harlem Hospital’s Methadone Treatment Program,Janet Aiyeku, CASAC and Dayo Alalade, Ph.D and the staff of Kings County Hospital’s Methadone Treatment Program

All the patients at HHC programs who have supported the development of contingency management and have evolved into some of the strongest advocates.

111111

And a special thanks to the And a special thanks to the researchers associated with the NIDA researchers associated with the NIDA CTN Project:CTN Project:

John Rotrosen, MD, NYU School of Medicine

Maxine Stitzer, Ph.D., John Hopkins University

Dr. Mary Jeanne Kreek at the Rockefeller University

NIH-NIDA Grants P60-DA05130 (Kreek), DA13046-04 (Rotrosen)

112112

CONTACT INFORMATION

Marylee Burns, MEd, MA,, CRC Marylee Burns, MEd, MA,, CRC Assistant Director, Assistant Director, NYC Health and Hospitals Corp.NYC Health and Hospitals Corp.212-788-3458;212-788-3458; [email protected]@nychhc.org

Peter Coleman, MS, CASACPeter Coleman, MS, CASACSenior Director, Senior Director, NYC Health and Hospitals Corp.NYC Health and Hospitals Corp.212-442-3993; 212-442-3993; [email protected]@nychhc.org

Scott Kellogg, Ph.DScott Kellogg, Ph.D., ., Clinical Psychologist, Clinical Psychologist, The Rockefeller UniversityThe Rockefeller University212-327-8282; 212-327-8282; [email protected]@rockefeller.edu

Peter Coleman, M.S., CASAC Marylee Burns, M.Ed., M.A., CRC Scott Kellogg, Ph.D.

Documents