peter coleman, m.s., casac marylee burns, m.ed., m.a., crc scott kellogg, ph.d. contingency...
TRANSCRIPT
Peter Coleman, M.S., CASAC
Marylee Burns, M.Ed., M.A., CRC
Scott Kellogg, Ph.D.
CONTINGENCY MANAGEMENT APPROACH:
IMPLEMENTATION AND OUTCOMES
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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
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Overview of NYC Health and Hospitals
Corporation and the Foundations of Change
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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 8 Methadone
Treatment ProgramsTreatment Programs 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!
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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.
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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.
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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
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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
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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
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Initial Actions and ResultsInitial Actions and Results
Initial 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 Reporting mechanisms put in mechanisms put in placeplace
Initial Results:Initial Results:
Nature of clinics Nature of clinics changed but culture changed but culture didn’tdidn’t
Treatment approach Treatment approach had punitive feelhad punitive feel
Patients did not respond Patients did not respond and retention declinedand retention declined
Staff disenchantedStaff disenchanted
Improvements Improvements unsustainedunsustained
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Reinvigorating the Process
Workgroupsexpanded 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
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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
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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!
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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.
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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
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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
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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
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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
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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
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Research on Research on Contingency Management Contingency Management Approaches in Substance Approaches in Substance
Abuse SettingsAbuse Settings
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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
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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
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REALITY CHECK…….
What REALLYmakes patients
come to treatment?
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Negative Consequences of Drug Use
Treatment
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Family MembersEmployersParole/ProbationChild Protective Services
External Negative Consequences
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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……...
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Drugs are Drugs are Positive Reinforcers
They Make They Make People People Feel Good.Feel Good.
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Drug Abusers Straddle Drug Abusers Straddle the Fencethe Fence
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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
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What are Motivational What are Motivational Incentives and How Can Incentives and How Can
They HelpThey Help
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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
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Examples of Rewards
Attention, Pat on the Back
Prizes and Gifts
Vouchers and Gift
Certificates
Privileges
Services
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Examples of Punishers
Fines Tickets Restriction
s Sanctions Displeasur
e
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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
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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
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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
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Rewards versus Punishments
Which is used more frequently?
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Punishments!Punishments!
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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
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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 - missed servicesservices
- certificates; key chains- certificates; key chains - probation- probation
- status/recognition- status/recognition - dismissal- dismissal
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Motivational Incentives Research
Clients earn vouchers for drug-free Clients earn vouchers for drug-free urinesurines– 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)
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Research on Research on Motivational IncentivesMotivational Incentives
Cocaine abusers in drug-free treatment Cocaine abusers in methadone treatment
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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
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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
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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
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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
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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
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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
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Adaptation into Adaptation into
Standard Clinic SettingsStandard Clinic Settings
Intermittent reward for good behavior reduces cost
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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
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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”
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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 of
education oneducation on
alcohol abuse weeklyalcohol abuse weekly
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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.
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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
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RetentionRetention
0
20
40
60
80
100
2 4 6 8
Weeks
Standard
Incentives
Petry et al., 2000
% R
eta
ined
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Time Until First Drinking Episode
0
20
40
60
80
100
2 4 6 8
Standard
Incentives
Petry et al., 2000
% A
bst
inent
Weeks
6262
Percent Positive for Percent Positive for Any Illicit DrugAny Illicit Drug
0
10
20
30
40
50
%
Intake Week 4 Week 8
Standard
Incentives
Petry et al., 2000
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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.
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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)
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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
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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
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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)
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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
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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
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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 Reinforcements should be given very frequently frequently
2. It should be very easy to earn reinforcements 2. It should be very easy to earn reinforcements at the start; the “bar” should be kept lowat the 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)
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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
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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
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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
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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 opportunity to explore with their patients what actions they took to avoid using drugs; what actions they took to avoid using drugs; this can be used to develop future coping this can be used to develop future coping strategies (Morral, Iguchi, & Belding, 1999)strategies (Morral, Iguchi, & Belding, 1999)
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The HHC Experience:
Implementation and Outcomes
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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
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Implementation - continued
Reinforcements were distributed in both group and individual settings.
Programs expanded upon existing award ceremonies.
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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.
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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:
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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 were lots of fights. Staff saw it as a negative at first…,. As the director, I negative at first…,. As the director, I allowed the staff to ventilate. The allowed the staff to ventilate. The Vocational staff started the whole process Vocational staff started the whole process because their orientation is far more because their orientation is far more receptive to this kind of thing.” (Program receptive to this kind of thing.” (Program Director)Director)
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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
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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
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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
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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.
Patients Reactions - continued
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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
Patients Reactions - continued
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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
Patients Reactions - continued
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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.
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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.”
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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
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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)
Counselor Experiences - continued
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Counselor Experiences - continued
“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.”
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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.”
Counselor Experiences - continued
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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.
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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.
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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) 60 172
Pay Stubs and Documentation of Employment Submissions 40 95
Harlem Hospital Vocational Outcome Data
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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.”
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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.”
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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.
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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.”
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Acknowledgements
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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
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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
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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.
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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)
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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