Promoting Awareness of Motivational Incentives: Focus on Founding Principles and an Implementation Checklist

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Promoting Awareness of Motivational
IncentivesFocus on Founding Principles and
anImplementation Checklist
PAMI
Donald A Calsyn, Ph.D. Pacific Northwest Node,
NIDA Clinical Trials Network Alcohol Drug
Abuse Institute University of Washington
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Course Content
Founding Principles Challenges Clinical
Applications
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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

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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

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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

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Choice of Reinforcer

• Reinforcer must be desirable
• Types traditionally utilized
• Clinic privileges
• Vouchers point systems
• Prizes
• Refunds
• Housing
• Employment

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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

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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

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Timing of the Incentive

• Immediacy is crucial.
• Best to have the reinforcer follow the target
  behavior very closely

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Consistency in Providing the Incentive

• Reinfocers need to be provided consistently
  across targeted patients
• Monitoring systems are needed to ensure this
  happens

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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

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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

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Course Content
Founding Principles Challenges Clinical
Applications
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Challenges

• Cost of incentives
• On-site testing
• Counselor resistance

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Challenges

• Is it fair?
• Does this lead
• to gambling
• addiction?

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Challenges

• Isnt this just rewarding patients for what
  they should be doing anyway?

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Challenges

• How do I select the rewards?
• Can Motivational Incentives be used with
  adolescents, or patients with co-occurring
  disorders?

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Emerging Adulthood Pilot Study SurveySample
Characteristic

• CTP n
• Triumph 77
• Residence-12 76
• Evergreen Manor 248
• Age
• 18-25 80 (20.0)
• gt25 308 (76.8)
• Gender
• Female 219 (54.6)
• Male 173 (43.1)

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Gift Card/Cash Preferences of Clients from 3 PNW
Node CTPs
p lt .05
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Gift Card/Cash Preferences of Clients from 3 PNW
Node CTPs

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Services/Assistance Preferences of Clients from 3
PNW Node CTPs
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Services/Assistance Preferences of Clients from 3
PNW Node CTPs
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Reward Schedule Preferences for Clients from 3
PNW Node CTPs
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Course Content
Founding Principles Low Cost Incentives
Clinical Applications
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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

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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?

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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

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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

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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

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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

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Contingency management worksheet Current
Procedures
CM Principle Current How to improve

Identify the Target Behavior
How is behavior measured
Target Population
Reinforcer/Punishment
Incentive Magnitude
Frequency of Incentive Distribution
Timing of the Incentive
Consistency in Providing Incentives
How is the program monitored
Duration of Intervention
Are successive approximations used
Is priming used
Escalating schedule or bonuses
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Contingency management worksheet Current
Procedures
Petry Checklist Item State Plan

Identify the Target Behavior Why? Occurrence frequency? Achievable by patients?
How is behavior measured
Target Population
Reinforcer Desirable? Available? Any Cost-if so how financed?
Incentive Magnitude
Frequency of behavior monitoring incentive Distribution
Timing of the Incentive
Consistency 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 I
Write out the contract
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Resources

• www.drugabuse.gov
• www.ATTCnetwork.org/PAMI
• www.samhsa.gov
• www.csat.samhsa.gov
• www.ATTCnetwork.org

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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

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Social Reinforcement Lash et al. 2004
?26.7, p.010
?24.0, p.047