Transcript Open slides - CTN Dissemination Library

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 Network
Alcohol & Drug Abuse Institute
University of Washington
Course Content
•
Founding Principles
• Challenges
• Clinical Applications
Founding Principles
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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
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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
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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, nonresponders, special populations,
users of a specific drug
Choice of Reinforcer
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Reinforcer must be desirable
Types traditionally utilized
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Clinic privileges
Vouchers – point systems
Prizes
Refunds
Housing
Employment
Incentive Magnitude
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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
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Options
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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
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Immediacy is crucial.
Best to have the reinforcer follow the
target behavior very closely
Consistency in Providing
the Incentive
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Reinfocers need to be provided
consistently across targeted patients
Monitoring systems are needed to ensure
this happens
Duration of the
Intervention
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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
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Successive approximations
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Priming
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If the target behavior is unlikely to occur
naturally, may need to reinforce behaviors
that approach the target
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
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Challenges
• Clinical Applications
Challenges
• 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
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How do I select the
rewards?
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Can Motivational
Incentives be used
with adolescents, or
patients with cooccurring disorders?
Emerging Adulthood Pilot Study Survey:
Sample Characteristic
• CTP
Triumph
Residence-12
Evergreen Manor
n
77
76
248
18-25
>25
80 (20.0%)
308 (76.8%)
• Age
• Gender
Female
Male
219 (54.6%)
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
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Identify target behavior
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Something you want to change
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Frequently occurring
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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
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Write out the behavioral contract
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Clarity is essential
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Be very specific
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Everyone needs to be on the same page
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Check for loopholes
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Identify any time limits
Nancy Petry Checklist-V
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Spell out implementation procedures
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How will the program be monitored?
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Consistency is essential
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Reminders to both staff and patients can be
very helpful
Nancy Petry Checklist-VI
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Plan for the future
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Review how the program functioned
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What seem to work
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What obstacles were unanticipated
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What was the patient response
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What new behaviors are to be targeted
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What changes will be implemented based on
what was learned
Contingency management worksheet:
Current Procedures
CM Principle
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
Current
How to improve
Contingency management worksheet:
Current Procedures
Petry Checklist Item
Identify the Target Behavior
How is behavior measured
Target Population
Reinforcer
State Plan
Why? Occurrence frequency? Achievable by
patients?
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
Resources
• www.drugabuse.gov
• www.ATTCnetwork.org/PAMI
• www.samhsa.gov
• www.csat.samhsa.gov
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www.ATTCnetwork.org
Social Reinforcement: Lash et al. 2004
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Participants: 28 day Inpatient TX completers
A-B design, Aftercare was either
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Standard
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Standard or Standard + Social Reinforcement
Written aftercare contract & attendance prompts
Social Reinforcement
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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