Using Motivational Incentives within Case Management Mark D. Godley, Ph.D. Chestnut Health Systems Bloomington/Normal, IL 35 th Annual Meeting of the Alabama Council of Community Mental Health Boards Birmingham, AL May 14, 2009 This work is supported by grants from the National Institute on Alcoholism & Alcohol Abuse, National Institute on Drug Abuse, and the SAMHSAs Center for Substance Abuse Treatment. The opinions are those of the author and do not reflect official positions of the government.

Purpose Describe how contingency management (CM) or motivational incentives work Vouchers vs. On-site Prizes Describe how CM can be implemented within a community based continuing care program following residential treatment Review the effectiveness of CM Discuss recommendations to improve effectiveness of CM

How does it work? Contingency Management or Motivational Incentives: Relies on close temporal association between the behavior to be increased followed by the reward. The contingency between the behavior and the reward is what changes behaviornot the reward alone. Choice of reward is important to sustain behavior change Rewards emphasize accomplishment and set postive expectation Petry & Stitzer (2003)

Contingency Management in Treatment of Substance Use Disorders Increase behaviors consistent with recovery such as: Schedule activities when adolescents might use Exposure to non-using peers Develop new or rekindle interest in pro-social activities Participation in treatment, 12-step meetings Activities with caregivers and family Many studies with adults Few studies with adolescents

CM Procedures Case manager met with adolescent at least once a week for 12 weeks post-discharge Breathalyzer test, urine screen administered/immediately tested Verification for the activities completed in the prior week and choose activities to complete in the next week Leisure questionnaire from Petry et al. Not rewarded for attendance, but if no-show, missed opportunity to draw for prizes Earned draws for verified completed activities and for providing negative breath and/or urine samples

CM Procedures Drew labeled slips of paper from fishbowl, potential to win a prize 510 slips in fish bowl Types of draws: Smiley faces (30%), small (62.8%), large (7%), or jumbo prizes (0.2%)

Draw Schedule for Clean UA Screens

Draw Schedule for Activities

Prizes Smiley face = no prize won Small = $1 prize (i.e., candy, snacks, soda, toiletries) Large = $25 prize (i.e., camera, CD player, gift certificates, perfume) Jumbo = $100 prize (i.e., gift certificates, DVD player, television, video game console) Chose prize from prize catalog and/or prize bag

Examples of Pro-Social Activities Education Obtain information about classes, register, do homework Employment Obtain job applications, submit applications, job interviews Family/friends Visit with family/non-using friends, attend parenting class Health Attend therapy, attend doctors appointments

Examples of Pro-Social Activities Legal See probation officer, community service, court dates Personal improvement Haircut, other salon services Sobriety Attend outpatient, 12-step meeting Social/recreational/household Music, reading, exercise, painting, church, chores Other

Four Randomized Conditions Usual Continuing Care (UCC) UCC + Assertive Continuing Care (ACC) No Contingency Management (No CM) Contingency Management (CM) No CM UCC No CM UCC + ACC CM UCC CM UCC + ACC

Participant Characteristics Mostly male (65%), Caucasian (64%) and 15 to 16- years-old (59%) Lifetime cannabis dependence (67%) Symptoms of internalizing disorders (58%) Symptoms of externalizing disorders (71%) Completed residential treatment as planned (56%) Left treatment against staff advice (29%) Left treatment at staff request (15%)

Usual Continuing Care (UCC) Refer back to treatment provider in home community About 56% received continuing care Type of services vary but tend to be outpatient or IOP

Assertive Continuing Care (ACC) Seven days or longer in treatment Uses home visits Sessions for adolescent, caregiver(s), and both sessions based on A-CRA manual (Godley, Meyers et al., 2001) Case Management based on ACC manual (Godley et al., 2006)

CM Results: Pro-Social Activities 97% completed one or more selected activity Mean activities selected = 20 Mean activities completed = 13 1,739 activities chosen; 1,114 (64%) completed 98% chose social/recreational activities Completed 64% of the time

CM Results: Pro-Social Activities 78% chose sobriety activities 52% of participants chose to attend at least one 12-step meeting; completed 58% of the time 50% of participants chose to attend outpatient treatment, completed 62% of the time 39% chose education, family/friends, legal, and household activities Completion rates ranged from 56% for personal improvement to 73% for household-related activities

CM Results: Consecutive Clean Urine Screens ACC + CM 53% abstinent for 4+ weeks 33% abstinent for 8+ weeks 16% abstinent for weeks (negative screens for entire continuing care period) UCC + CM 58% abstinent for 4+ weeks 38% abstinent for 8+ weeks 15% abstinent for weeks (negative screens for entire continuing care period)

Treatment Outcomes for AOD Use

Stability of Outcomes for AOD Use

Percent of Days Abstinent from AOD Use

Percent of Days Abstinent from Heavy Alcohol Use, while in the Community

Conclusions It is possible to implement motivational incentives for adolescents with severe problems to increase pro-social activities and clean urine screens. The program can be implemented through a home visiting case management approach or in the office Cost of incentives was under $ Motivational Incentives worked but did not have the long term effectiveness of ACC

Recommendations Specifically contract for activities that compete with high-risk using times of the week. Use A-CRA Functional Analysis of Substance Use Identify possible behaviors that would be incompatible with substance use Use A-CRA Functional Analysis of Pro-Social Behavior Leisure Questionnaire used in A-CRA Increase effectiveness of motivational incentives: Increase prize values Improve odds of drawing large prizes Increase frequency of prize drawings

For More Information Mark Godley Chestnut Health Systems 448 Wylie Drive Normal, IL Godley, S.H., Godley, M.D., Wright, K.L., Funk, R.R., & Petry, N.M. (2008). Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care. American Journal on Addictions, 17 (4),