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Practical Application of Contingency Management

Practical Application of Contingency Management. Michael J. McCann, MA Matrix Institute on Addictions. Elements of Treatment: Information, Persuasion, and Medication. Information Matrix Model CBT 12-Step Persuasion Motivational Interviewing Confrontation Contingency Management.

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Practical Application of Contingency Management

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  1. Practical Application of Contingency Management Michael J. McCann, MA Matrix Institute on Addictions

  2. Elements of Treatment: Information, Persuasion, and Medication • Information • Matrix Model • CBT • 12-Step • Persuasion • Motivational Interviewing • Confrontation • Contingency Management

  3. Motivational Interventions • If you build it they will not necessarily come. • And, if they do come, they may not come all of the time. • Hence: • Motivational Interviewing • Contingency Management

  4. Contingency Management (CM) • CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities). • Research consistently shows that it works.

  5. Contingency Management: Overview • Research findings • Application of CM in the Matrix Institute OTP

  6. Research Findings • Highlight efficacy • Raise questions about real-world applicability

  7. Contingency Management: Steve Higgins, Ph.D. • Community Reinforcement Approach (CRA) • Marital Therapy • Vocational Assistance • Skills Training • New social and recreational activities • Antabuse • Vouchers ($977)

  8. Contingency Management: Higgins et al., 1993 • 24-week treatment • 3 times per week urines • Conditions • Standard treatment • CRA plus vouchers

  9. Contingency Management: Higgins et al., 1993

  10. Contingency Management: Higgins et al., 1994 • How much of CRA effect is CM? • 24-week treatment • 3 times per week urines • Conditions • CRA only • CRA plus vouchers

  11. Contingency Management: Higgins et al., 1994

  12. Contingency Management:Rawson et al., 2002 • Cocaine-using methadone patients • 16 weeks; 3 X per week • Four conditions: • CM • CBT • CBT & CM • Methadone only

  13. Contingency Management: Rawson et al., 2002 • Cognitive-behavioral Treatment (CBT) • 90 minute groups • Cognitive/behavioral • Drug cessation • Lifestyle change • Relapse prevention

  14. Contingency Management: Rawson et al., 2002 • Contingency Management • Vouchers for stimulant-free urines • Progressive schedule • Bonuses for 3 consecutive clean ($10) • Reset with 5 clean • Total earnings possible: $1277

  15. Cocaine-free Urine Samples During StudyRawson et al., 2002 P<.001 CM>MM CBT & CM>MM

  16. Percent Subjects Achieving 3 Consecutive Weeks Cocaine-freeRawson et al., 2002 P<.02 CM>MM CBT & CM >MM

  17. Days used cocaine in past month Rawson et al., 2002 Week 26: CM<MM; CBT<MM Week 52: CBT<MM

  18. CBT Group AttendanceRawson et al., 2002 P<.04

  19. Contingency Management in Treatment • Conclusion: CM works

  20. CM in Practice • What to target? • Urine results? • Frequent enough? Results immediate? • Valid? Observed? • Treatment goals • Can vary across patient and counselors • Verifiable? • Attendance

  21. CM in Practice • Challenges • Addressing staff resistance • Patients should not have to be “paid”; recovery is the reward • Motivation needs to come from within

  22. CM in Practice • Challenges • Must be simple • Easy to track—Need to keep a record of attendance • Easy to figure rewards—no progressive schedules, resets, etc. • Little burden on the counselor

  23. CM in Practice • Challenges • Must be inexpensive • A less expensive method may be a bit less effective, but an expensive method will never be used. • A little reward goes a long way especially combined with praise and recognition

  24. CM in Practice in an OTP • $5 per month for perfect group attendance • $5 per month for perfect medication attendance • Easy to track • Less expensive than CM in research

  25. Perfect medication attendancePre-post contingencies, n=49 P<.05

  26. Perfect group attendancePre-post contingencies, n=49 P<.01

  27. Perfect group attendance in patients missing pre-CM, n=20

  28. Groups attended in patients missing pre-CM, n=20 P<.005

  29. CM in an OTP: Conclusions • A simple, low cost CM intervention can improve patient attendance in groups and medication visits.

  30. CM in an OTP: Modifications • Recent data show diminished effect • Perfection too difficult? • More immediate effect; shaping: McDonald’s coupons, once per week at group, first 30 days of treatment

  31. CM in an OTP: Modifications • Raffles • Voucher for 1-1 sessions • 2 vouchers qualifies for group raffle the following month • Reinforces attendance in 1-1 and groups • Relatively inexpensive • No tracking required

  32. Conclusions • CM can be effectively used in clinical settings • Low cost reinforcers can be effective • Simple schedules can be effective • Increased attendance can offset cost with fee-for-service billing

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