Contingency Management for Substance Abuse Treatment

A Guide to Implementing This Evidence-Based Practice

Nancy M. Petry

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138400931
• eBook ISBN: 9781136699443
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Isn't it unethical to pay people to do what they should be doing anyway?
Won't patients just sell the reinforcers and buy drugs?
Others didn't get prizes for not using. Why should they?

The concerns surrounding Contingency Management (CM) are many and reflect how poorly understood and rarely utilized this evidence-based treatment model is in practice settings. Despite being identified as the most efficacious intervention for substance use disorders, a significant gap persists between research and practice, at the client's expense. Nancy Petry, an experienced researcher and consultant for organizations such as the National Institute of Health, has begun to fill this gap by authoring the first clinician-oriented text that focuses on CM protocol development and implementation. In this well-organized and clear book she provides a foundation for understanding CM and details how to design and implement a program that can work for any clinician, whether he or she works for a well-funded program or not. She also addresses realistic concerns such as:

• How to describe CM to eligible and ineligible patients
• How to calculate the costs of CM interventions
• How to solicit donations and raise funds to support CM interventions
• How to stock a prize cabinet and keep track of prizes

Over 50 charts, worksheets, and tables are provided to help the clinician pinpoint exactly which behaviors to target, brainstorm how to reinforce change, and develop a treatment plan that incorporates cost, length of treatment, and method for determining patient compliance. Included with the book are downloadable resources of editable logs, forms, tables, and worksheets for personal use. More than just filling a void, Dr. Petry provides all of the tools clinicians require to successfully apply a novel treatment in practice.

III

Implementing Contingency Management in Practice

Chapter 12

Getting Started

Stocking a Prize Cabinet and Obtaining Other Needed Supplies

Once your CM schedule is developed and costs of the CM program are determined and deemed appropriate, the actual process of CM implementation can begin. The first part of this chapter outlines items that are needed beyond the prizes themselves. Then, specific issues related to how to start a prize cabinet and maintain prize inventories are described. In terms of patient-specific issues, the chapter also outlines how to talk with eligible patients about participating in a CM program, how to explain non-participation to ineligible patients, and how to address common staff concerns. From this point forward in this book, I focus on two CM protocols: prize CM that reinforces abstinence individually and Name-in-the-hat prize CM that reinforces group attendance. CM protocols that utilize other reinforcement systems or reinforce other behaviors can adapt the relevant materials outlined below to address similar issues.

12.1 CM RELATED ITEMS

A number of items need to be obtained or created to start a CM program, beyond just the prizes themselves. These include a prize bowl, a lockable cabinet, and urine testing supplies (if applicable). I recommend you purchase the cabinet prior to obtaining the prizes, because you need a cabinet in which to store the prizes.

12.1.1 Prize Bowl

You can purchase a plastic fishbowl from a department or pet store. It should cost under $10 and be sufficiently large that you can put your (or a large) fist into it. You will also need 500 square (three-inch by three-inch) sticky pad pieces of paper (assuming your fishbowl contains 500 slips; see ). All pieces of paper in your bowl should be of the same color (preferably a dark color so that the paper is opaque and you cannot see the writing through the other side of the paper). There is a reason to use only one color of paper in your bowl. If patients find out that the jumbo prize is on a pink slip of paper but there are also blue slips in the bowl, they will preferentially select pink slips.

You can either purchase a stamp set or simply write “small” on the appropriate number of these pieces of paper, given your probability configurations determined in . For the example reinforcing abstinence on an individual basis, you would write “small” on 209 of the 500 slips. You should write on the “sticky” side of the paper, so that you can then fold the sticky side together twice. The final piece of paper that goes in the bowl is one-fourth its original size and should be a perfect square.

You will also write or stamp the appropriate number of slips with the word “large.” In our example, 40 slips are designated as large prizes. One slip has the word “jumbo.”

The remaining slips (in this case, 250) state, “good job!” Although some therapists have wanted to include inspirational sayings on non-winning slips, you can see that it would require a great deal of imagination to come up with 250 inspirational sayings. It may also be difficult to fit sayings onto slips without being able to tell that some slips contained more writing than others.

For the example related to reinforcing group attendance using the Namein-the-hat prize CM procedure, you would need only 100 square sticky pad pieces of paper for the prize bowl. You would write “small” on 69 of them, “medium” on 20, “large” on 10, and “jumbo” on one.

Some therapists have elected to print out slips of paper, rather than using the sticky pad method outlined above. If you choose to print out papers, it may actually end up being more complicated than writing them out by hand on sticky pads. It would be essential that all slips that you printed out were the exact same size and that you could not see the writing through the slips of paper. A cautionary tale comes from one clinic. They prepared regular white paper with letters G, S, L, and J printed on them. They put the 500 slips in a prize bowl, and within two weeks of initiating the CM program, patients were drawing larges over 50% of the time! The L symbol could be seen and distinguished from the Gs and Ss, even when the slips were folded. Hence, the patients quickly learned the contingencies—pick a slip that looks like it has an L on the inside.

Another cautionary note is to use the same colored pen (and handwriting or stamp) on each slip. As will be described later, in a section about how to prevent “cheating,” the ink and handwriting can be utilized to identify any inappropriate picking behaviors (see Exhibit 12.3).

12.1.2 Other Stationery Supplies Needed for Name-in-the-Hat Prize CM

For Name-in-the-hat prize CM that reinforces group attendance, you will need additional sticky pad pieces of paper on which to write patients’ names. As patients’ names may go into the “hat” up to 1+2+3+4+5+6+7+8+9+10 = 55 times (for perfect attendance over a 10-week period), you may need up to 55 × 20 (1,100) slips if there are 20 patients to be enrolled in the CM program. For the name slips, I recommend using different colors every week (with some repeats in colors over time). You need to use the same color slips for every patient each week (otherwise, patients who draw the names from the hat may look for their own colored slips). However, you also ought to vary the color slips on a random basis so that patients do not know what color slip will be used on a given week (and try to insert additional name slips of their own; see Exhibit 12.3 later in this chapter on how to prevent inappropriate picking behaviors). Thus, you should purchase about five to 10 different colored sticky pads.

For this system, you will also need envelopes in which to place the patients’ name slips and their reminder slips. You will need up to 10 envelopes per patient × 20 patients = 200 envelopes if it is a 10-week protocol with about 20 patients participating.

Finally, you will also need a “hat” into which you will place the name slips each week. Although technically you need not purchase a hat and can use any container, buying a plastic hat that can stand upside down (has a flat top) makes the program’s name true to form. You can find plastic hats of this shape at a party store or online. A baseball cap may also work.

12.1.3 Lockable Prize Cabinet

Regardless of the form of prize CM you are instituting, you will need a fairly large cabinet that can house all your prizes, including the jumbo items that are often bulky (e.g., television, stereo). Preferably, the cabinet should have doors that open out and contain four or five shelves. It must be lockable. Examples of prize cabinets are shown in Figure 12.1.

FIGURE 12.1 Sample prize cabinets.

The prize cabinet should be housed in a room that also gets locked. Ideally, it will be stored in a location in which only limited access is allowed or one that is so busy that any tampering would be readily noticed. You will probably not want to place a prize cabinet in an individual therapist’s office, unless that is the only therapist using the cabinet. Otherwise, that therapist will be constantly interrupted each time a patient comes in to select prizes. Ideal locations are often areas near restrooms, in photocopy rooms, in group rooms, or in a lockable hallway closet or small office that is rarely used. In determining the location for the prize cabinet, one needs to consider ease of access in terms of prize selections for the patients immediately after having their results tested, along with considerations about the potential for theft. You certainly would not want to place a prize cabinet in the outside entryway of a clinic or in an area that cannot be well secured at night.

In setting up your prize cabinet, you will store all the small prizes on the top one to two shelves, mediums (if applicable) on another shelf, larges on yet another shelf, and the jumbos on the bottom shelf. The prize cabinet should always be locked, and opened only during CM sessions. The prize bowl should also be locked inside the prize cabinet, when not in use, to prevent tampering.

12.1.4 Urine Testing Supplies

Before starting a CM program that reinforces abstinence, you may also need to purchase urine testing supplies. You will want to determine which onsite testing system to use. Some states, insurers, or clinics may have regulations about the use of urine testing procedures, and these should be consulted as necessary. In addition, costs can vary quite substantially across manufacturers. If you are planning on purchasing large numbers of urine tests, you may be able to get a reduced price. These issues were discussed in .

In addition to testing kits, you will need ancillary supplies: cups to collect the samples (unless you are using a test cup, as opposed to a test stick); gloves; and tamper devices you may choose to use, such as temperature strips, pH meters, or adulterant checks. Some test cups have temperature strips included on them, and temperature strips can also be purchased separately. AdultaCheck^® (Scitech, Inc., Arden, NC) is a commercially available test strip that detects some common methods of urine adulteration. It does this by indicating whether the urine sample shows normal ranges for creatinine, pH, glutaraldehyde, and nitrates. If the test indicates that the urine is outside normal range on any of these features, it can be counted as invalid, as outlined later in Chapter 13.

12.2 STARTING A PRIZE CABINET

To begin the process of buying prizes for your prize cabinet, you must become familiar with your clinic’s regulations on purchasing, and you need to decide what prizes to purchase. You will have to purchase the items, and you will need to initiate a system to keep track of your purchases. These steps are outlined below.

12.2.1 Clinic Regulations on Purchasing

Some clinics will have a credit card that you can use to directly purchase the items you want. In other cases, there may be a petty cash account, and you can obtain the desired amount of cash and purchase prizes. In still other situations, you need to buy items with your own funds and then submit a request for reimbursement. If this later situation arises, you will want to be sure you are aware of the time it takes to process reimbursements (often six to eight weeks). If you are implementing prize CM, staring a prize cabinet will cost about $400. If your clinic has no other mechanisms than to reimburse you, you may be carrying a $400 debt for up to two months. You may also want to be sure you receive something in writing that states that expenses will be reimbursable to ensure that you do not end up being responsible for the costs of some or all of the prizes.

No matter what the situation is in your clinic, you want to be sure to retain legible receipts for CM purchases. It is always a good idea to make a photocopy of the receipts for your own records in case the originals get lost. When shopping, you should not intermix personal shopping with CM shopping. Most clinics will look unfavorably on splitting items on a receipt. If you pick up something for yourself while shopping for prizes, just pay for it separately, so that your own items are not rung up on the same receipt as the CM prizes. If your clinic is not-for-profit, be sure to get a copy of its taxexempt number so that you need not pay taxes on the prize purchases.

12.2.2 Determining Initial Prizes

As noted in earlier chapters, most prize bowls contain small ($1), large ($20), and jumbo ($100) items. Thus, you will need an ample selection of prizes in each category. There are two ways you can go about deciding upon prizes, and these two methods are not mutually exclusive. You can survey patients in your clinic (ideally ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• The Author
• Author’s Note and Preface
• SECTION I. Foundations for Understanding
• SECTION II. Designing a Contingency Management Intervention
• SECTION III. Implementing Contingency Management in Practice
• SECTION IV. Conclusion
• References
• Index