Contingency Management An Evidence Based Approach to Improving Treatment Adherence Dr. John Mahan, MD, Addiction Psychiatrist Jackson County Mental Health Disclosures I have no relevant financial disclosures to make
No non-FDA approved uses for medications will be discussed Learning Objectives Gain familiarity with the behavioral principles underpinning Contingency Management Learn about voucher-based vs. prize-based reinforcement paradigms, understand how an escalating schedule of reinforcement can be applied to either, and appreciate that these interventions do not cause or destabilize Gambling Disorder.
Introduce how one ACT Team has implemented Contingency Management to reinforce desired prorecovery behaviors, including A&D group attendance, meeting with medical providers, and presenting for longacting injectable medication administration. The Conundrum How to encourage clients to meet with clinicians, adhere to medications, or abstain from methamphetamine? Benefits: Better Physical and Mental Health Improved Relationships Social Productivity
The Conundrum To clients, the benefits of treatment plan adherence can be long-term, and therefore less immediate, than other competing factors Benefits: Better Physical and Mental Health Improved Relationships Social Productivity Competing Priorities In service of Long Term Benefit
Meeting with clinicians Medication adherence Abstinence from methamphetamine, cannabis, or other substances Competing Forces Negative symptoms, disruptive to daily life
Avoiding side effects, a nuisance to remember Cravings, Avoidance of withdrawal, Desired alteration in perception of symptoms or difficult life circumstances What is Contingency Management? A way to bring positive consequences for treatment adherence forward in
time and to make them: More immediate More salient More predictable What is Contingency Management? Based on Operant Behavioral Principles, also known as Instrumental Learning or Operant Conditioning If I do this, then that happens Operant vs. Classical OPERANT CONDITIONING Stimuli that are present when a behavior is rewarded (or punished)
affect the likelihood of the behavior in the future a thought process CLASSICAL CONDITIONING Stimuli that signal significant events produce reflexive behavior - often outside conscious awareness e.g., Getting to the ACT meeting early because
you know there will be donuts and the best ones go fast! e.g., Salivating at the sight of your favorite treat! but we are not the only ones who know this... A chance at free cannabis entices someone to enter a cannabis dispensary. Winning free cannabis makes it more likely an
ACT client will return to the dispensary for another chance to win. so we should offer our own reinforcers Contingency Management uses immediate positive reinforcers to improve adherence to treatment plan elements that might otherwise have mostly long-term benefits.
Immediacy Target a behavior that you can reinforce in real time (ideally not a delayed reward) Attending an appointment with a clinician Attending a group Successfully providing a laboratory sample (regardless of result) Appropriate Urine Drug Screen (point of care is best for immediacy of Value The reinforcers have to be valuable to the participants (but they dont have to be
expensive). Ask participants what they want! Adolescents often dont want CDs, for example Id rather give health food, but participants often desire less nutritious snacks Can allow participants to bank points for larger items they would like Fixed vs. Intermittent Reinforcement
FIXED INTERMITTENT Fixed vs. Intermittent Reinforcement FIXED Reinforcement is always the same, no chance involved Vouchers are often used
INTERMITTENT Half the prizes are verbal encouragement, some are worth a little, a few are worth a bit more, and one can be pretty nice Works equally well as a fixed
paradigm, and is cheaper to run Does NOT contribute to development of (or relapse to) Gambling Disorder FUN! Prizes can be vouchers or tangible reward Option: Escalating Schedule An Escalating Schedule can be applied to either Fixed or Intermittent reinforcement structures to improve efficacy (data show escalating works better!)
Number of reinforcers increases with each successive successful behavior (up to a maximum), until participant misses an opportunity to display the desired behavior Option: Escalating Schedule CONSTANT SCHEDULE
First: 1 Misses one: 0 First: 1 Second in a row: 1 Misses one: 0 First: 1 Second in a row: 1
Third in a row: 1 Fourth in a row: 1 Fifth in a row: 1 Sixth in a row: 1 Seventh in a row: 1 ESCALATING
First: 1 Misses one: 0 First: 1 Second in a row: 2 Misses one: 0 First: 1 Second in a row: 2 Third in a row: 3 Fourth in a row: 4 Fifth in a row: 5 Sixth in a row: 5 Seventh in a row: 5
How long to continue? Continue to reinforce the behavior with contingency management at least until the long-term benefit of the behavior has been realized, and perhaps longer. How long to continue? This might be a long time, but why not? If it was worth it to start, continuing is worth it
Instead of stopping a reinforcer that is working, add a new behavioral target to a successful program for a given participant How to Get it Funded This helps clients engage with medically necessary treatment. If thats not enough, sell it to your administrators by showing how the cost of the program could be offset by a decrease in lost productivity: Missed appointments with your psychiatrist or other internal medical providers Low productivity due to missed groups or
sessions with other providers How to Make a Starting Budget Decide fixed vs intermittent (cheaper) Decide constant vs escalating (better) Decide how many will participate Decide how many target behaviors per
participant How many chances per month for a participant to demonstrate a target behavior for a reinforcement? Calculate (average) value of reinforcement How to Make a Starting Budget Fixed Value, Constant Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Value E.g., 20 ACT clients can earn a $1 by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment
=20 x (2+4+1) x $1 = $140 How to Make a Starting Budget Fixed Value, Escalating Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Value x highest consistency multiplier E.g., 20 ACT clients can earn a $1 by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. They can earn up to 5 $1 bills if they attend five or more in a row. =20 x (2+4+1) x $1 x 5 = $700 (but only if attendance were consistently perfect) How to Make a Starting Budget
Intermittent Value, Constant Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Average Prize Value E.g., 20 ACT clients can earn a prize by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. The Average Prize value is $0.50 =20 x (2+4+1) x $0.50 = $70 Calculating Average Prize Value Divide the total value of all possible prizes by the total number of chances to win a
prize. Ignore the free spin slots Calculating Average Prize Value 16 terminal slots 8 are free 5 are worth 100 points 2 are worth 200 points 1 is worth 500 points (0+500+400+500)/ 16 =$0.87 average if
Ignore the free spin slots How to Make a Starting Budget Intermittent Value, Escalating Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x highest consistency multiplier x Average Prize Value E.g., 20 ACT clients can earn a prize by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. They can earn up to 5 spins if they attend five or more in a row. The Average Prize value is $0.50. =20 x (2+4+1) x 5 x $0.50 = $350 How to Budget
These calculations have given us an idea of where to start with an initial budget, but operating costs will be much lower (unless everyone is perfect all the time!) Use actual expenditures over the first several months to make future budgets. If you have more funding than you are spending, add more behavioral targets or
improve value of prizes. Jackson County ACT Team Medium sized ACT Team Methamphetamine, Cannabis, and Alcohol Use complicate response to treatment Tobacco-related illness will cause the death of most consumers of specialty mental health
services We wanted to increase engagement in treatment Jackson County ACT Team Average cost is currently about $10 a month per ACT client on the team, though a subset of the clients are the most active
I am glad that I have no idea what budget it comes out of. Jackson County ACT Team Attendance increased within 4 months of introduction of Contingency Protocols, and has remained improved: Mens Group increased from 2 to 9 EIMR Coed increased from 4 to 14
Womens group increased from 4 to 7 Jackson County ACT Team We originally kept candy and snacks on a shelf for instant rewards, but our building manager told us we couldnt keep food around We switched to points that are
redeemable for gift cards (can select so they are not redeemable for alcohol or tobacco) Jackson County ACT Team Points are tracked in an excel spreadsheet. 500 points = $5 gift card Most popular gift cards are Walmart, Dollar Tree, McDonalds, Subway, and Taco Bell
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