1. 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

2. Course Content Founding Principles Challenges Clinical Applications

3. 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

4. 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

5. 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

6. Choice of Reinforcer Reinforcer must be desirable Types traditionally utilized – Clinic privileges – Vouchers – point systems – Prizes – Refunds – Housing – Employment

7. 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

8. 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

9. Timing of the Incentive Immediacy is crucial. Best to have the reinforcer follow the target behavior very closely

10. Consistency in Providing the Incentive Reinfocers need to be provided consistently across targeted patients Monitoring systems are needed to ensure this happens

11. 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

12. 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

13. Course Content Founding Principles Challenges Clinical Applications

14. Cost of incentives On-site testing Counselor resistance Challenges

15. Is it fair? Does this lead to gambling addiction? Challenges

16. Isn’t this just rewarding patients for what they should be doing anyway? Challenges

17. How do I select the rewards? Can Motivational Incentives be used with adolescents, or patients with co- occurring disorders? Challenges

18. Emerging Adulthood Pilot Study Survey: Sample Characteristic CTP n Triumph 77 Residence-12 76 Evergreen Manor248 Age 18-25 80 (20.0%) >25308 (76.8%) Gender Female219 (54.6%) Male173 (43.1%)

19. Gift Card/Cash Preferences of Clients from 3 PNW Node CTPs *p <.05

20. Gift Card/Cash Preferences of Clients from 3 PNW Node CTPs *

21. Services/Assistance Preferences of Clients from 3 PNW Node CTPs

23. Reward Schedule Preferences for Clients from 3 PNW Node CTPs

24. Course Content Founding Principles Low Cost Incentives Clinical Applications

25. 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

26. 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?

27. 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

28. 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

29. 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

30. 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

31. CM PrincipleCurrentHow to improve 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 Contingency management worksheet: Current Procedures

32. Petry Checklist ItemState Plan Identify the Target Behavior Why? Occurrence frequency? Achievable by patients? How is behavior measured Target Population Reinforcer 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 monitoredWho? How? Reminders? Ensure consistency Duration of Intervention I Write out the contract Contingency management worksheet: Current Procedures

33. Resources www.drugabuse.gov www.ATTCnetwork.org/PAMI www.samhsa.gov www.csat.samhsa.gov www.ATTCnetwork.org

34. 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 6 th group & name on honor roll ‾ Medallion at 8 th group

35. Social Reinforcement: Lash et al. 2004 Χ 2 =6.7, p=.010Χ 2 =4.0, p=.047