2. 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 1 Contingency Management in Community Treatment Programs Issues in Implementation Allan J. Cohen, M.A., M.F.T. Director of Research and Development

3. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 2 Discussion of Contingency Management evokes very strong emotional responses

4. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 3 What is Contingency Management (CM)?

5. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 4 I. Very powerful Behavioral Intervention Behavioral Contracting Structuring the environment to positively reinforce (reward) appropriate (desired) behaviors Negatively reinforce undesired behaviors (withdraw/withhold positive reinforcers)

6. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 5 II. A very NATURAL and EXPECTED Paradigm Childrearing shaping behaviors Employment raises, bonuses, awards Education report cards, privileges People are generally accepting of basic philosophy/tenets since they are “used to it.”

7. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 6 III. Has been used for many years in Substance Abuse Treatment Methadone Maintenance take home medications/program privileges 12-step programs chips/anniversary cakes Therapeutic communities/ Residential Programs Step Program/privileges

8. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 7 Contingency Management has been shown to be effective in Substance Abuse Treatment Retention in treatment Decrease in illicit drug use Medication compliance Attendance at clinic Attendance at counseling sessions

9. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 8 Types of Reinforcers Cash Vouchers Take home meds Fishbowl / Prizes Program Privileges Special hours Steps/Levels Passes Food Rebates

10. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 9 Community Treatment Provider Issues/Concerns (Barriers to Implementation) Sustainability Cost of CM Staff time Staff training Inconsistent with program philosophy Does not build “internal” motivation for change Not yet strong evidence in community treatment programs CTN Some evidence

11. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 10 Considerations in support of Contingency Management Evidence Based – many research studies addressing a variety of issues Many funding sources/contracts tied to evidence based treatment & outcomes Powerful change agent Good patient acceptance Need to employ most effective treatment strategies Lends itself well to outcomes measurement Can tailor to individual patient needs May also be utilized with staff Medications engendered much resistance, are now more accepted: Dual Diagnosis Antabuse Methadone/LAAM

12. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 11 ~Thoughts~ Question is not if it works, but how to make it work in CTP’s Efficiently Effectively Feasibility Develop creative, low cost reinforcers Naturally occurring Social Material Assist clients to achieve treatment goals with greatest degree of potential success Develop contracts funding which builds in support for CM (outcomes bases funding) Participate in research projects(CTN) which can help us to learn

13. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 12 A SAMPLE OF POSITIVE REINFORCEMENT

14. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 13 MANAGEMENT IQ QUIZ

15. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 14 Question #1: How do you put a giraffe into a refrigerator?

16. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 15 Answer: Open the refrigerator, put in the giraffe and close the door. This tests whether you tend to do simple task in an overly complicated way.

17. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 16 Question #2: How do you put an elephant into a refrigerator?

18. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 17 Answer: Open the refrigerator, take out the giraffe, put in the elephant and close the door. This tests your ability to think through the repercussions of your previous actions.

19. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 18 Question #3: The Lion King is hosting an animal conference. All the animals attend except for one. Which animal does not attend?

20. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 19 Answer: The Elephant. The Elephant is in the refrigerator. You just put him in there. This tests your memory.

21. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 20 OK, even if you didn’t answer the last three questions correctly, you still have one more chance to show your true abilities….

22. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 21 Question #4: There’s a river you must cross but it is inhabited by crocodiles. How do you manage it?

23. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 22 Answer: You swim across. All the animals are attending the Animal Meeting. This tests whether you learn quickly from your mistakes.

24. Contingency Management in Community Treatment Programs 10/15/2003 Copyright 2003 Aegis Medical Systems, Inc. All rights reserved. 23 Conclusion: According to Anderson Consulting Worldwide, around 90% of professionals they tested got ALL questions wrong. However, many pre-schoolers got several questions correct. This conclusively disproves the theory that most professional have the brains of a 4 year old!