PAMI

Promoting Awareness of Motivational Incentives:

Focus on Founding Principles and an

Implementation Checklist

Donald A Calsyn, Ph.D.Pacific Northwest Node, NIDA Clinical Trials NetworkAlcohol & Drug Abuse InstituteUniversity of Washington

Course Content

• Founding Principles• Challenges

• Clinical Applications

Founding Principles• Identify the Target Behavior• Choice of the Target Population• Choice of the Reinforcer/Incentive• Incentive Magnitude• Frequency of Incentive Distribution• Timing of the Incentive• Consistency in Providing Incentives• Duration of Intervention

Identify the Target Behavior

Target behavior is something in need of change

Must be objectively observable & measureable

Must be reasonably obtainable Examples: urines, attendance, goal

obtainment steps

Choice of Target Population

May not be feasible or necessary to target everyone

Target only those groups or individuals where the target behavior is a problem

Examples: new patients, non-responders, special populations, users of a specific drug

Choice of Reinforcer Reinforcer must be desirable Types traditionally utilized

– Clinic privileges– Vouchers – point systems– Prizes– Refunds– Housing– Employment

Incentive Magnitude Chose a reinforcer that can compete

with reinforcement derived from target behavior

In general the greater the magnitude the more effective is the reinforcer

However, low magnitude reinforcers have been effective

Frequency of Incentive Distribution

Options– Reinforce every time target behavior occurs– Reinforce intermittently– Reinforce within a set schedule The schedule of reinforcement and

contingency link must be clearly stated

Timing of the Incentive Immediacy is crucial. Best to have the reinforcer follow the

target behavior very closely

Consistency in Providing the Incentive

Reinfocers need to be provided consistently across targeted patients

Monitoring systems are needed to ensure this happens

Duration of the Intervention

How long dose the incentive program remain in force?

For long term recovery to occur patients need to internalize the process

Recovery needs to become reinforcing

Additional Considerations Successive approximations

– If the target behavior is unlikely to occur naturally, may need to reinforce behaviors that approach the target

Priming– May need to provide the reinforcer before

target behavior performed so patient can become familiar with getting reinforced

Escalating reinforcers and bonuses

Course Content

• Founding Principles

• Challenges• Clinical Applications

• Cost of incentives

• On-site testing

• Counselor resistance

Challenges

• Is it fair?

• Does this lead

to gambling

addiction?

Challenges

• Isn’t this just rewarding patients for what they should be doing anyway?

Challenges

How do I select the rewards?

Can Motivational Incentives be used with adolescents, or patients with co-occurring disorders?

Challenges

Emerging Adulthood Pilot Study Survey:Sample Characteristic

• CTP nTriumph 77

Residence-12 76Evergreen Manor 248

• Age18-25 80 (20.0%)>25 308 (76.8%)

• GenderFemale 219 (54.6%)Male 173 (43.1%)

Gift Card/Cash Preferences of Clients from 3 PNW Node CTPs

*p < .05

Gift Card/Cash Preferences of Clients from 3 PNW Node CTPs

*

Services/Assistance Preferences of Clients from 3 PNW Node CTPs

Services/Assistance Preferences of Clients from 3 PNW Node CTPs

Reward Schedule Preferences for Clients from 3 PNW Node CTPs

Course Content

• Founding Principles

• Low Cost Incentives

• Clinical Applications

Nancy Petry Checklist-I• Identify target behavior

• Something you want to change• Frequently occurring• Reasonably achieved by the patients

• Indicate how behavior will be objectively measured

Nancy Petry Checklist-II

• Chose a reinforcer

Needs to be desired

Needs to be of sufficient magnitude

• Is it readily available?

Clinic privileges

• If there is a cost how will you pay for them?

Nancy Petry Checklist-III• Use behavioral principles to establish

the reinforcement schedule How frequently will behavior be monitored?

How frequently will behavior be reinforced?

Honor the immediacy principle Will successive approximations or priming be needed Will an escalating schedule or bonuses be used

• Keep it simple Patients and staff need to be able to understand and follow the system

Nancy Petry Checklist-IV• Write out the behavioral

contract• Clarity is essential• Be very specific• Everyone needs to be on the same page• Check for loopholes• Identify any time limits

Nancy Petry Checklist-V• Spell out implementation

procedures• How will the program be monitored?• Consistency is essential• Reminders to both staff and patients can

be very helpful

Nancy Petry Checklist-VI• Plan for the future

• Review how the program functioned• What seem to work• What obstacles were unanticipated• What was the patient response

• What new behaviors are to be targeted• What changes will be implemented

based on what was learned

CM Principle Current How to improve

Identify the Target Behavior

How is behavior measured

Target PopulationReinforcer/PunishmentIncentive MagnitudeFrequency of Incentive Distribution

Timing of the IncentiveConsistency in Providing Incentives

How is the program monitored

Duration of Intervention

Are successive approximations used

Is priming usedEscalating schedule or bonuses

Contingency management worksheet: Current Procedures

Petry Checklist Item State Plan

Identify the Target Behavior Why? Occurrence frequency? Achievable by patients?

How is behavior measuredTarget PopulationReinforcer Desirable? Available? Any Cost-if so how

financed?Incentive MagnitudeFrequency of behavior monitoring & incentive Distribution

Timing of the IncentiveConsistency in Providing Incentives

Are successive approximations used?

Is priming used?Escalating schedule or bonuses

Implementation: How is the program monitored

Who? How? Reminders? Ensure consistency

Duration of Intervention IWrite out the contract

Contingency management worksheet: Current Procedures

Resources

• www.drugabuse.gov

• www.ATTCnetwork.org/PAMI

• www.samhsa.gov

• www.csat.samhsa.gov www.ATTCnetwork.org

Social Reinforcement: Lash et al. 2004

Participants: 28 day Inpatient TX completers A-B design, Aftercare was either

‾ Standard or Standard + Social Reinforcement

Standard‾ Written aftercare contract & attendance prompts

Social Reinforcement‾ Group therapist special recognition session 1‾ Certificate at 6th group & name on honor roll‾ Medallion at 8th group

Social Reinforcement: Lash et al. 2004

Χ2=6.7, p=.010 Χ2=4.0, p=.047