Using Motivational Incentives within Case Management Mark D. Godley, Ph.D. Chestnut Health Systems Bloomington/Normal, IL 35 th Annual Meeting of the Alabama.

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

[email protected]

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.