Adapting Evidence-based Treatment
to Clinical Practice :
How to use Low Cost Incentives
Regional Dissemination Workshop
June 3, 4, 2010
Baltimore, MD
Workshop Agenda
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Reward vs. Reinforcement
Choice/Magnitude of the Reinforcer
Target Behavior/Target Population
Different Kinds of Delivery
Fiscal Concerns
Successful Implementation
Lori Peterson, Director
Lane Treatment Center
• Design & Implementation
Reward vs. Reinforcement
A central issue in all
incentive dissemination
efforts!
Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M., Wale, J. B.,
& Kreek, M. J. (2005). Something of value: The introduction of
contingency management interventions into the New York City
Health and Hospital Addiction Treatment Service. Journal of
Substance Abuse Treatment, 28, 57-65.
Reward vs. Reinforcement
• When drug abuse staff or leadership speak about
the use of incentives, they usually talk about
acknowledging patients for things like:
– Holding a job for six months
– Being drug-free for 3 months
– Completing a GED or vocational training
program
Reward Programs
A reward program acknowledges patients for achieving
a goal or accomplishing something noteworthy:
– Most likely give rewards to the best and most
motivated patients
– While often not changing the behavior of those
patients who are struggling the most with drug
use and treatment compliance
Reinforcement Programs
Whereas a Reinforcement Program…
– Breaks down each of the goals into very
small steps
– Reinforces each of the steps along the way
– Makes it easy to earn a reinforcement
– Distributes reinforcements with fairly high
frequency
Reinforcement Programs
Move from “You have done a good job” to
“You have taken a step in the right direction”
This is the most important change that a
reinforcement plan can make in your
treatment program!
Incentive vs. Reward
Which of these is an incentive?
Which of these is a reward?
So, how about…
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A draw from the fishbowl for showing up on time?
A bag of candy for pts. who are one month clean?
A pizza party after 12 weeks of attendance?
A prize for returning to have your TB test read?
A smiley face sticker for group attendance?
Sodas and snacks at the Cocaine Anonymous Group?
A chance to win a raffle prize based on attending each
orientation group?
Proximal (near) vs. Distal (far)
Reward
Individual or group prizes for achieving
a particular goal (Distal)
Incentive
A reinforcer (Proximal)to motivate or propel
forward an individual or group
to help achieve a particular goal.
It’s not only what you give,
but when you give it.
Target Behavior
The “reinforcement” model emphasizes
breaking the goal down into very small steps
and then reinforcing each of the steps as they occur.
The behavior must be observable and measurable.
Choosing a target behavior involves something problematic or in
need of a change. Then, the new behavior becomes a
contingency.
and…
…the chance of winning needs to
be reasonably attractive
Pizza Hut Book It!
Setting = classroom
Target group = school children
Target behavior = increased reading
Reinforcer = one "book buck" (play money)
for each book read
Verification = self-report + parent signs
“Bucks” could be cashed in at a store open
once per week.
Prize examples:
- pencil or eraser costs one buck
- BOOK IT! pins cost two bucks
- folders cost three buck
other items included paperback books,
frisbees, and designer shoelaces
Students could cash in all the bucks they had
or use part of them and save the rest. What
they bought was entirely up to them. It
really encouraged them to read!
Changing the status quo?
What needs changing at your agency…
Poor group attendance?
Spike in cocaine use?
Medical appt. no-shows?
Lack of early engagement?
Refusal to pay fees?
This will help you decide on your….
Target Behavior
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Attendance at first post-intake appointment
Regular attendance at group therapy
Kept medical appointments
Regular payment of fees
Cocaine abstinence (negative urines)
Target Population
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Is it the whole agency?
Is it the people who loiter out front?
Is it the patients with Medical Assistance?
Is it the prevalent cocaine users?
Is it the Women’s group, or the Men’s group?
Is it new patients?
Is it the staff?
Back on My Feet
Back on My Feet
is much more than just running.
It is a comprehensive program that
offers connections to job training,
employment and housing, but
these benefits are not free.
Members earn the opportunity to
move forward in the six month to
nine month program by
maintaining a 90 percent
attendance rate at the morning
runs three days a week.
backonmyfeet.org
Man Alive
We think the world of you!
• Target Behavior: Keep your insurance current
• Target Population: Managed Care Patients
• Incentive: $5 and $10 gift cards to CVS, Dunkin’
Donuts and Safeway
• Contingency: Bring your DSS letter in for
review/receive a $5 gift card; show proof of
keeping your re-con appt. receive a $10 gift card.
• Delivery: immediate
• Followup- thank you note from administration
w/keychain.
Delivery Styles, Timing
and Frequency
Which will you choose?
Fishbowl, Raffle, Vouchers, Token Economy
The token, point, or voucher is delivered when the
target behavior is exhibited.
How much money, staff resources and contact
you have to offer will influence the frequency
of delivery.
Low cost prizes!
This is a
craft
item!
12 for
$5.99
You can order these
on-line with your own
recovery sayings!
Consider buying
different cost
items to create
escalation!
You can order these by the
dozen, and the price goes
down if you buy 3 dozen!
Make it seasonal! As you get closer
to the holiday, the price goes down!
Or, how about…
a treasure chest
filled with prizes for clients
to choose their own prizes.
Jim Bieting’s Recovery Cart– filled
with small prizes and 12 Step
materials. Locked, rolling cart from
Craftsman Tools.
Or, how about:
a bulletin board for new patients--recording their success,
earning the chance to win a raffle as they climb the
mountaintop!
Or, how about..
a case management
tic-tac-toe board
charting both: kept
appts. tasks to be
completed, and
honoring length of
stay!
BCRC/Case Management
Tic Tac Toe!
Client’s Name___________________
SECOND
Task:
THIRD
VISIT:
VISIT:
FIRST
Task:
Task:
VISIT:
FOURTH
VISIT:
Task:
14 DAY
ANNIVERSARY!
With each of these efforts,
what are we after?
Time!
Give clients time to internalize
the recovery process and
develop naturally re-occuring
reinforcers.
Lane Treatment Center
The Lane Treatment Center specializes in
substance abuse and mental health treatment,
offering individual counseling, traditional
outpatient groups, and an intensive outpatient
program.
What is an incentive? How does one
differ from a reward?
• Webster’s definition: Something that incites or tends to incite
action or greater effort, as a reward for increased productivity
• An incentive is a specific type of reward
• An incentive is given to a person for completing a desired behavior
• The person is told about the incentive before he completes the
behavior
• The magnitude of the incentive should match the magnitude of the
effort to complete the behavior
Attendance Spreadsheet
Data Summary Table
Total Patient Contacts
Non-Incentive vs. Incentive Period
AM Group (Tuesday, Wednesday, Friday )
June 2007 – October 2008
Lane Treatment Center IOP
200
180
160
140
120
100
80
60
40
20
0
Non-Incentive Period
Incentive Period
Average Patients Per Group
Non-Incentive vs. Incentive Period
AM Group (Tuesday, Wednesday, Friday )
June 2007 – October 2008
Lane Treatment Center IOP
16
14
12
Non-Incentive Period
10
8
6
4
2
0
Incentive Period
Average Groups Attended Per Patient
Non-Incentive vs. Incentive Period
AM Group (Tuesday, Wednesday, Friday )
June 2007 – October 2008
Lane Treatment Center IOP
8
7
6
Non-Incentive Period
5
Incentive Period
4
3
2
1
0
Monthly Insurance Income vs. Incentive Cost
Non-Incentive vs. Incentive Period
AM Group (Tuesday, Wednesday, Friday)
June 2007 – October 2008
Lane Treatment Center IOP
$20,000
$18,000
Income vs. Incentive
$16,000
Income
$14,000
$12,000
$10,000
Incentive
Cost
Incentives
Non-Incentive Period
$8,000
$6,000
$4,000
$2,000
$0
Incentive
Period
Fishbowl Method
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24
8
12
4
8
“Applause”
"Keep it Up!"
"Good Job"
"Keep Coming Back"
"Hear from your Peers“
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35
15
5
1
"Small"
"Medium"
"Large"
"Jumbo“ (pt’s choice)
• 56 no-cost tickets, and
• 56 cost tickets for a total of 112.
Motivational Incentives
Fishbowl contains:
•Applause
•Hear from your peers
•Small
•Medium
•Large
•Jumbo (patient’s choice)
Prize cabinet is bookshelf
kept in locked office.
Prize cabinet is re-stocked
with patient input, so prizes
change to keep interest
going.
Target
audience:
IOP
participants
Target
behavior:
Consistent
attendance
Lessons Learned
 Data is invaluable to funding sources/administrative
supervisors/Boards
 Importance of patients’ choice
 Element of surprise and positivity
 Immediate reinforcement (daily)
 Revenues generated greatly outweigh expenditures
 Ease of tracking, monitoring using charts/graphs
 Multiple levels of prizes used (small, medium, large, jumbo) is
key for “spending” vs. “saving” lessons
 Return to baseline periodically (non-incentive period) to
re-assess effectiveness
Break time!
3:15 -3:30
During the break,
take some time to
confer with others
about what’s
percolating.
Design & Implementation
Pick a target behavior
Pick a target population
Pick an incentive
Choose the frequency of the incentive
Choose the timing of the incentive
Estimate a cost schedule
Start out small to keep it manageable!
Tell us your ideas
for a chance to win a prize!
Presenter gets two draws.
Each group member gets one draw.
Stay Solution Focused!
• Lack of leadership support
Use resources in PAMI, CTN Dissemination Library,
to drum up support
• Lack of funds
Start out small/use no cost incentives
• Lack of staff enthusiasm
Try incentivizing them!
• Lack of good monitoring
Hire a grad student as an intern