pami promoting awareness of motivational incentives: focus on founding principles and an...
TRANSCRIPT
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 NetworkAlcohol & Drug Abuse InstituteUniversity of Washington
Course Content
• Founding Principles• Challenges
• Clinical Applications
Founding Principles• 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
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
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, non-responders, special populations, users of a specific drug
Choice of Reinforcer Reinforcer must be desirable Types traditionally utilized
– Clinic privileges– Vouchers – point systems– Prizes– Refunds– Housing– Employment
Incentive Magnitude 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
Options– 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 Immediacy is crucial. Best to have the reinforcer follow the
target behavior very closely
Consistency in Providing the Incentive
Reinfocers need to be provided consistently across targeted patients
Monitoring systems are needed to ensure this happens
Duration of the Intervention
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 Successive approximations
– If the target behavior is unlikely to occur naturally, may need to reinforce behaviors that approach the target
Priming– 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
• Challenges• Clinical Applications
• 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
How do I select the rewards?
Can Motivational Incentives be used with adolescents, or patients with co-occurring disorders?
Challenges
Emerging Adulthood Pilot Study Survey:Sample Characteristic
• CTP nTriumph 77
Residence-12 76Evergreen Manor 248
• Age18-25 80 (20.0%)>25 308 (76.8%)
• GenderFemale 219 (54.6%)Male 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• Identify target behavior
• Something you want to change• Frequently occurring• 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• Write out the behavioral
contract• Clarity is essential• Be very specific• Everyone needs to be on the same page• Check for loopholes• Identify any time limits
Nancy Petry Checklist-V• Spell out implementation
procedures• How will the program be monitored?• Consistency is essential• Reminders to both staff and patients can
be very helpful
Nancy Petry Checklist-VI• Plan for the future
• Review how the program functioned• What seem to work• What obstacles were unanticipated• What was the patient response
• What new behaviors are to be targeted• What changes will be implemented
based on what was learned
CM Principle Current How to improve
Identify the Target Behavior
How is behavior measured
Target PopulationReinforcer/PunishmentIncentive MagnitudeFrequency of Incentive Distribution
Timing of the IncentiveConsistency in Providing Incentives
How is the program monitored
Duration of Intervention
Are successive approximations used
Is priming usedEscalating schedule or bonuses
Contingency management worksheet: Current Procedures
Petry Checklist Item State Plan
Identify the Target Behavior Why? Occurrence frequency? Achievable by patients?
How is behavior measuredTarget PopulationReinforcer Desirable? Available? Any Cost-if so how
financed?Incentive MagnitudeFrequency of behavior monitoring & incentive Distribution
Timing of the IncentiveConsistency 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 IWrite out the contract
Contingency management worksheet: Current Procedures
Resources
• www.drugabuse.gov
• www.ATTCnetwork.org/PAMI
• www.samhsa.gov
• www.csat.samhsa.gov www.ATTCnetwork.org
Social Reinforcement: Lash et al. 2004
Participants: 28 day Inpatient TX completers A-B design, Aftercare was either
‾ Standard or Standard + Social Reinforcement
Standard‾ Written aftercare contract & attendance prompts
Social Reinforcement‾ 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