Journal of Substance Abuse Treatment 28 (2005) 57 – 65
Regular article
Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service Scott H. Kellogg, (Ph.D.)a,*, Marylee Burns, (M.Ed.), (M.A), (CRC)b, Peter Coleman, (M.S.), (CASAC)b, Maxine Stitzer, (Ph.D.)c, Joyce B. Wale, (CSW)b, Mary Jeanne Kreek, (M.D.)a a The Rockefeller University, New York, NY, USA Office of Behavioral Health, The New York City Health and Hospitals Corporation, New York, NY, USA c Johns Hopkins School of Medicine, Baltimore, MD, USA
b
Received 15 May 2004; received in revised form 20 September 2004; accepted 28 October 2004
Abstract This paper explores the impact of the adoption of the contingency management approach by the Chemical Dependency Treatment Services of the New York City Health and Hospitals Corporation (HHC). The utilization of this approach grew out of an alliance between NIDA Clinical Trials Network-affiliated clinicians and researchers and a leadership team at the HHC. Interviews and dialogues with administrators, staff, and patients revealed a shared sense that the use of contingency management had: (1) increased patient motivation for treatment and recovery; (2) facilitated therapeutic progress and goal attainment; (3) improved the attitude and morale of many staff members and administrators; and (4) developed a more collegial and affirming relationship not only between patients and staff, but also among staff members. D 2005 Elsevier Inc. All rights reserved. Keywords: Contingency management; Positive reinforcement; Addiction treatment; Methadone; Vocational rehabilitation
1. Introduction The process of institutional change can appear complex and intimidating. This paper tells the story of the successful adoption of a new empirically-based treatment, contingency management (CM), by a diverse array of chemical dependency treatment programs within the largest public hospital system in the nation. The project involved the collaboration of scientifically-oriented researchers and clinicians from the Clinical Trials Network (CTN) of the National Institute on Drug Abuse (NIDA) and an innovative leadership team
from the New York City Health and Hospitals Corporation (HHC), a public benefit corporation in which the treatment programs reside. When the project moved out into the field, the hard work and creativity of the counselors and other clinical staff who further refined the contingency management programs and implemented them in their clinics and the enthusiasm of the patients were key ingredients in making it a success.
2. The Health and Hospitals Corporation 2.1. Background
* Corresponding author. Box 171, The Rockefeller University, 1230 York Avenue, New York, NY 10021-6399, USA. Tel.: +1 212 327 8282; fax; +1 212 327 7023. E-mail address:
[email protected] (S.H. Kellogg). 0740-5472/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2004.10.007
The New York City Health and Hospitals Corporation was established as a public benefit corporation in 1970 and is a large municipal health care provider, with 11 acute-care
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hospitals, six diagnostic and treatment centers, four longterm care facilities, over 100 community health clinics, a managed care organization (MetroPlus), and a certified home health care agency. In addition to primary heath care, HHC provides a full array of mental health and chemical dependency services, operating over 1,200 inpatient behavioral health beds that generate 20,520 patient discharges per year, and outpatient services that generate over 472,000 visits a year. The array of chemical dependency treatment programs within HHC facilities includes: eight methadone treatment programs, 19 outpatient chemical dependency treatment programs, eight inpatient detoxification units, two halfway houses, a residential program run in partnership with a community-based provider which offers a medication taper and added support for those patients wishing to discontinue their methadone treatment, four hospital intervention and referral services, and an intensive case management program. At the start of the collaboration, HHC had been engaged in a process of evaluating their treatment structures and developing practice guidelines in order to improve treatment outcomes through increased focus on recovery, self-sufficiency, and employment. 2.2. An agency in transition In 1998, HHC was awarded funds by the New York State Office of Substance Abuse Services (OASAS) to add a vocational rehabilitation counseling component in five of its methadone clinics. The award stipulated that the clinics needed to revise their programs to reflect an integration of vocational and clinical services and develop a bworkerfriendlyQ culture. The following year, after methadone treatment in New York City was directed to place a strong focus on self-sufficiency, additional funds were provided by the City to further enhance the services offered by HHCTs methadone treatment and drug-free outpatient programs by enhancing their vocational services. In 2000, there was a second award of funds from OASAS, which added still more vocational resources. With this infusion of funds, HHCTs methadone clinics underwent a profound structural and philosophical change, reflected in a conscious decision to change clinic names from methadone maintenance to methadone treatment programs. A workgroup made up of physicians, program administrators, and representatives from various disciplines standardized practice guidelines and revised clinic manuals for all of the methadone programs. Clinics and staff were strongly encouraged to embrace rehabilitation, recovery, and self-sufficiency both philosophically and as primary treatment goals. It was expected that evening and Saturday hours of operation would be added, caseloads would decrease, and more intensive counseling services including group treatment would be offered. Career centers, equipped with computers, vocational tests, videos, workbooks, video cameras, televisions, and VCRs, were also established in each clinic. Program administrators meet regularly and worked closely with
corporate staff to share ideas and address obstacles, and a statistical reporting system was instituted to collect and analyze data. Similar changes were also being put into place in the outpatient chemical dependency programs. The second wave of efforts to foment institutional change and facilitate staff bbuy-inQ included an HHC-organized, day-long workshop for administrative and line staff of the methadone programs entitled Multidimensional Solutions in Substance Abuse Treatment: Thinking Outside of the Box. The training emphasized not only the importance of respecting the patientTs values, wishes, and culture, but also the need to be aware that change was a cyclical, individual process. In addition, clinics were encouraged to adopt the transtheoretical model of behavioral change as a guiding principle in developing treatment plan goals and matching interventions. OASAS assisted by making available a 2-day training entitled Project Invest that focused on the integration of vocational rehabilitation into the treatment process. A third phase of interventions began when HHC developed, funded, and launched a Patient Recognition and Motivation Initiative in the fall of 2001. This initiative was based on research and experience that supported the use of tokens to encourage and motivate patients to attain treatment goals. Recognition of patient achievements was felt to be a valuable mechanism to acknowledge success and the attainment of treatment goals, to further a positive self image, to provide staff and peer support, and to motivate others by furnishing peer models they could emulate. HHC initially developed a recognition plan template that was expected to serve as a model for the clinics to use in developing their own, individual plans. Programs interested in participating in this initiative had to submit a detailed plan for the establishment and ongoing support of a Motivation and Patient Recognition Initiative. The primary focus of this initiative was to be on vocational goals, with substantial emphasis on employment and employment retention. However, recognizing that this is but one piece of drug treatment, and that barriers to recovery and employment are many, Motivation and Recognition Initiatives were also required to be developed in such a way to recognize advancement in treatment and attainment of other significant milestones as well. It was at this point that the HHC leadership came into contact with researchers actively engaged in implementing contingency management protocols.
3. Contingency management The use of contingency management or positive reinforcement approaches in the treatment of addictive disorders has received increasing levels of attention in recent years as scientific studies continue to demonstrate its efficacy with diverse substance-using populations (Higgins, Alessi, & Dantona, 2002; Petry, 2000; Petry, Martin, Cooney, & Kranzler, 2000; Petry et al., 2001; Silverman et al., 1996; Stitzer, Iguchi, Kidorf, & Bigelow, 1993). As a reflection of
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this development, the contingency management approach was one of the first chosen to be tested by the CTN. Called Motivational Incentives to Enhance Drug Abuse Recovery, the protocol was primarily aimed at cocaine and methamphetamine use among participants in methadone and medication-free treatment settings. One of the goals of NIDA and the CTN is the dissemination of effective, research-based interventions into the broader community-based treatment field. To this end, NIDA has been involved in the creation of a series of Blending Conferences—conferences in which treatment providers and scientifically-oriented researchers and practitioners can meet, dialogue, and, hopefully, form alliances to help move the treatment field forward. It was at the NIDA Blending Conference in New York in March of 2002 that the two groups first made contact—an encounter that fulfilled one of the ambitions of the conference organizers. The CTN faculty and HHC leadership met and a partnership emerged. The partners then visited the front-line clinics that were interested in being a part of this motivational initiative and discussed their plans with them.
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and brewardQ is incorrect. They are both forms of reinforcement. The difference is that the criteria in the brewardQ condition is much greater than that in the breinforcementQ condition. Nonetheless, in our dialogues with the staff and the administrators at the clinics, the use of the social constructs of breinforcementQ and brewardQ appeared to be quite meaningful and this reconceptualization of the process led to the development of more effective plans.
5. Engaging the clinics In order to lay the foundation for an effective intervention, presentations were made to the clinic leadership and to the staff at each of the five clinics by Dr. Scott Kellogg, covering the theory, practice, and research findings on contingency management interventions in substance-abuse settings (Mid-Atlantic Node, 2000), as well as patient experiences from other CM projects within the CTN. In this process, several core principles concerning the use of reinforcements were emphasized in our presentations to the staff and the leadership (see also Kirby, Amass, & McLellan, 1999). These were:
4. From rewards to reinforcements Although the programsT plans reflected an understanding of reinforcement principles, the majority of the interventions occurred too long after the targeted behaviors. The plans that were being developed were designed to brewardQ patients for achieving major accomplishments—going to groups on a regular basis, finishing a vocational training program, keeping a job for 30, 60 and 90 days, and being drug- and alcohol-free for 2 months. In a sense, it was a program to reward bvirtue,Q as the incentive/token comes after the completion of significant progress toward recovery. There also seemed to be a risk that this kind of intervention would only have an impact on the bbestQ patients, i.e., those who were already very motivated and high functioning. In turn, the CTN group felt that transforming the intervention into a breinforcementQ system would increase the likelihood of reaching and motivating patients who were currently the least responsive to treatment and most in need of help (Petry & Bohn, 2003). Contingency management programs can be designed to reinforce each of the small steps and each of the components that are involved in reaching the goal, not just the attainment of the goal. They can be more gradualistic and the focus is more on using motivational approaches to initiate and maintain behavior change. Again, especially early in the process, it can be helpful if the reinforcements are easy to earn and distributed frequently (Kazdin, 1994). This way, not only the most motivated patients, but also those who are more troubled and/or more severely addicted have the opportunity to benefit (see also Petry et al., 2001). From a strictly behavior-analytic perspective (Kazdin, 1994; Wolpe, 1982), this distinction between breinforcementQ
1. Reinforcements should be given very frequently. 2. It should be very easy to earn reinforcements at the start. The bbarQ should be kept low. As an example, there was a discussion about the fact that when the trainers at Sea World begin to teach the whales to jump over the hoops, they start with the hoop being under the water, and the whales are given reinforcements for simply swimming over it (Coonradt, 1996). 3. To be as effective as possible, the reinforcements needed to include material goods and services, and these need to be of use and value to the patients. Social reinforcement alone was not likely to be as effective, especially for patients who were disconnected or socially phobic. 4. The reinforcements would be most effective if their distribution was directly connected to specific and observable behaviors and if they received them immediately after they exhibited the behavior (i.e., attending the group). The greater the delay in receiving the reinforcement, the weaker its effect was likely to be (Kazdin, 1994). 5. Counselors and staff were encouraged to focus on the good things that the patients did, not their failings. In this vein, any steps in the right direction were a cause for celebration, and in the face of setbacks, patients should be encouraged, not criticized. A few other clinical points were emphasized as well. The criteria for earning a reinforcement should be clear to both the patients and the staff members. All eligible participants who met the criteria were entitled to receive the reinforcement regardless of whether or not he or she were meeting other treatment objectives. In addition, the staff members
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who were not enthusiastic about this intervention or even opposed to it were offered a chance to exclude themselves from the distribution of reinforcement/tokens as they might inadvertently have a damaging impact on its efficacy (Petry & Bohn, 2003). Again, a congratulatory approach was seen as the appropriate one. It was also emphasized that, despite some of the exciting findings, contingency management programs were not a substitute for counseling, but an adjunct to it. In terms of the cessation of alcohol or drug use, reinforcements strengthen behaviors that lead to abstinence. Counselors have a valuable therapeutic opportunity to explore with their patients what actions they took to refrain from using substances and then utilize this information to clarify and develop the patientTs coping techniques and strategies. As has been noted elsewhere (Morral, Iguchi, & Belding, 1999), it is important to clarify which techniques patients are using to maintain abstinence, as some will have a greater likelihood of being sustainable over the long run than others. For example, patients who are maintaining sobriety by isolating themselves in their homes probably will not do as well as patients who are practicing drug- and alcohol-refusal skills and creating networks of nonsubstance-using friends (Morral et al., 1999). This scientific presentation by Dr. Kellogg was complemented with one by Ms. Marylee Burns from the Office of Behavioral Health at HHC who spoke about how progress in the vocational domain could have a positive impact on drug use and vice versa. This meant that reinforcements used to change one kind of behavior could potentially impact other behaviors as well. Papers on the use of contingency management (i.e., Petry et al., 2000, 2001) were also distributed to staff, and clinics were provided with reassurances that the financial resources needed to make these programs work would be made available.
6. Data collection Information about the contingency plans, the reaction of staff and patients, and the outcomes of the interventions were ascertained from a variety of sources. Initial visits and meetings with the administrators in each of the clinics took place during the Summer of 2002. Each of the participating programs submitted progress reports between December, 2002 and February, 2003, and, during the summer of 2003, Dr. Kellogg and Ms. Burns again visited four clinics and met with staff, administrators, and, in one case, patients. Other sources of information included letters from patients and videotaped interviews with staff and patients done in the fall of 2003. In the Spring of 2004, the HHC made a decision to expand the use of contingency management to additional clinics as well. To help create enthusiasm and to facilitate technology transfer, an in-house conference was organized and all of the facilities and staff in the HHC system were invited to attend. This conference was called, bScience in
the Trenches: Contingency Management at HHCQ and it was held in June, 2004. This was a two-part conference that included presentations by national experts on past and current research on the use of contingency management in addiction and other settings. In the afternoon presentation, each of the five clinics had numerous members of their staff describe their program, discussed the process of adoption, and report on the response of the patients. This paper has been based on information gathered from all of these sources, and the quotes chosen for the text are those that were felt to reflect the processes and themes that emerged as salient in these dialogues and encounters.
7. Implementation 7.1. Reinforcement models Although all adhered to the basic principles of reinforcement, the five treatment sites differed in the models they implemented. With the exception of Program 2, these were all methadone treatment programs. In Program 1, each patient received a piece of candy and a raffle ticket when they attended a group. At the end of the group, there was a raffle and the reinforcement/token was a $4 bMetro CardQ (transportation card). Patients could also save their tickets and use them, instead, in a raffle for larger reinforcement/ tokens. After attendance improved at the site, the program created a series of benchmarks that included such topics as achieving stable housing, demonstrating consistency in attending the program, and improving skills connected to activities of daily living. Patients were given reinforcements for achieving these benchmarks as well. The program was then further expanded to include reinforcing patients who brought another patient to a group for the first time; patients who had been promoted to the role of group leader were rewarded by being taken out to dinner. Program 2, which was a medication-free program, combined the use of material reinforcements with social reinforcements. This program focused, for the most part, on patients who had recently entered treatment. They set three criteria for reinforcement: (1) completion of all of the initial assessments; (2) a week with one negative urine toxicology report; or (3) a week with attendance at 80% or more of scheduled groups. For the distribution of reinforcements, the program used an expansion of their Monday morning community meeting. The names of patients who had achieved one of these criteria in the previous week were announced and they were honored and applauded by the staff and patients. In PetryTs intermittent reinforcement model (Petry, 2000; Petry et al., 2000), patients received prizes on some occasions and verbal reinforcements on others. The impetus behind this ratio reinforcement model was to reduce the cost of the intervention. Initially, Program 2 used this kind of model. Patients put their hand in a bfishbowlQ and pulled out a chit. Some of these could be
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turned in for prizes, while others had bgood jobQ written on them. This approach was found to be unpopular with both patients and staff so the model was changed to one in which every chit was worth a reinforcement/token of some tangible value. Not only were reinforcements given for meeting these criteria, but also patients received reinforcement/tokens for achieving such benchmarks as getting a GED, completing training, getting a job, and keeping a job. These Monday morning meetings turned out to be very dramatic and emotional events, and they were well attended by both patients and staff. As the Director reported, this community approach had a number of benefits: (a) it helped create a positive atmosphere; (b) it brought the whole clinic—staff and patients—together; (c) it served to model progress in recovery for newer patients; and (d) it acknowledged and affirmed the progress that clients had made. Patients would frequently discuss these meetings, and they were looked upon with great anticipation. Lastly, this clinic also used reinforcement/tokens in an ad hoc way to help engage very isolated and disconnected patients. Program 3 focused on vocational issues. Patients received a reinforcement/token after attending each vocational group. When they had completed a cycle of four vocational groups, they received a $25 gift certificate for a department store. They received a similar certificate when they completed the 8-week cycle. In addition, McDonaldTs certificates were given to patients after submitting five totally negative toxicology reports. Program 4 developed an interactive computer program that played an integral role in their system. Patients received points for each group that they attended and these points could be cashed in for reinforcement/tokens. At the end of each day, counselors provided the names of all of the patients who had attended groups and a designated staff member entered the data into the system. The next day, patients could log in and see how many points they had. The computer provided information on the kind of gift certificates that were available and a history of how they had used their points in the past. When the patients were ready to cash in their points, the staff member in charge of the data entry assisted them in finding the best store to purchase what they wanted. She even helped them look through the paper for sales. Program 5 reinforced behaviors associated with vocational and educational involvement, clinic attendance, group attendance, and the achievement of treatment goals. The primary focus, however, was on encouraging patients to attend a vocational or GED class. Each time they attended a session, they received $5 in an escrow account. After they attended their fifth class, they were given a $25 gift certificate. A visual chart was created for each patient, and they received a notation (check/star) for the date they attended a group. This also served to give them a visual representation of their progress. For other benchmarks, patients, initially, were given recognition at the quarterly celebrations. Again, wrestling
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with the brewardQ vs. breinforcementQ issue, the program was planning to change this model in order to provide reinforcements that were closer in time to the manifestation of the desired behavior. 7.2. Reinforcements distributed The actual reinforcements used included movie passes, transportation vouchers (bmetro cardsQ), McDonaldTs coupons, calendars, gift certificates for major department stores and music outlets, date books, tools, clothes, books, T-shirts, microwaves, water bottles, sunglasses, things for children, toiletries, food, and candy. Programs also instituted or expanded upon award ceremonies. Across sites, receiving a certificate or a reinforcement for gains made in their recovery could be a very emotional experience with numerous reports of patients bursting into tears. 7.3. Process considerations The interactions at the clinics between the staff and the leadership were complex and exciting. In some ways, the clinics were quite different from each other; however, certain concerns and themes kept re-emerging. A central concern was that not all patients would be treated bfairlyQ; that is, have equal access to reinforcements. This seemed to be less of an issue with the mechanics of the proposed plan, and more a reflection of the empathic connection of the counselors with their patients. The importance of enabling as many patients as possible to be eligible for reinforcements was reflected in the final plans developed by the clinics. Dynamic program leadership was essential to successful implementation. In each of the five clinics where a positive reinforcement program was actually implemented (two treatment facilities did not develop a program), there was a director who put his or her authority behind it, and who consistently pushed the staff to make the program a reality. The process of creating and initiating these programs was met with resistance. As Backer and David (1995) noted in their comments on technology transfer, bchange is hard Q (p. 263). This may particularly be the case when the treatment strategy is contingency management. As Petry and Bohn (2003) have observed, many people oppose contingency management until they see its impact on the patients; once they see that, their attitudes begin to change. This same process appeared to be at work in the HHC clinics. Typically, the counseling staff were the last to bsign onQ to the idea. Factors such as philosophical differences, a fear that it would add to their workload, a sense of exhaustion and burnout, or a combination of all of these may have contributed to this resistance. Two processes appeared to combat this and to seemed to contribute to the eventual staff endorsement of the approach. The first was that the clinic leadership typically organized a number of meetings in which feelings and issues related to the use of reinforcements were aired and
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explored. The Director of Program 1 described the events in his clinic: bThis was a long and hard process and there were lots of fights. Staff saw it as a negative at first. . . As the Director, I allowed staff to ventilate. The vocational rehabilitation counselors started the whole process because their orientation is far more receptive to this kind of thing.Q The second process was that once some of the patients began to earn reinforcements, others began raising the issue, with some urgency, with their counselors. When initially resistant staff saw the impact it was having on their clients, many came to believe in its value.
8. Patient, staff, and clinic experiences 8.1. Patient experiences As noted above, patients were very enthusiastic about the program. Some initially met the idea that they would get a reinforcement/token for attending a group with disbelief; they had to actually see the reinforcement/token before they would believe that it was not a trick. The staff reported that they believed that the patientsT self-esteem was rising and that they were becoming more empowered. They based this view on their observation that there were improvements in the patientsT appearance, and that the patients began to speak about pursuing goals—typically of a vocational or educational nature. Clients were saying. . . bIn Russia, we were forced into treatment–Now (crying), my God, ITm getting treatment and $25.00!Q (Program 2) A core issue here was the profound emotional and economic deprivation that these patients had experienced and continued to experience. The reinforcements may have been powerful because some came to believe through the reinforcements that the staff cared about them. Staff believed that the reinforcements got them to the groups and motivated them to stay, and then the power of the group began to have its impact, as has been observed elsewhere (Petry et al., 2001). Patients who participated in the clinics that offered reinforcement programs often began to become more socially integrated. First, their sense of connection to the program grew and they participated more freely in its events. bThe staff have heard clients say that they had come to realize that there are rewards just in being with each other in group. There are so many traumatized and sexually abused patients who are only told negative things. So, when they hear something good—that helps to build their selfesteem and ego. (Program 4 Director) As one patient put it, dI used to think the drug dealer cared for me, but this is really caring.TQ (Program 4 counselor) In a number of poignant stories, patients used their department store gift certificates to buy presents or needed
items for their children or other family members. In a number of cases, these actions began a process of reconciliation. (See also Petry & Bohn, 2003, for a similar story.) Lastly, patients began to connect more with each other. In some clinics, patients who earned coupons for movies would go together in groups. There were also reports that patients in some programs were beginning to take care of each other and give each other gifts. As noted above, an internalization process took place in which patients took increasing ownership and responsibility for the program. As the Director from Program 1 put it, they went from bYou are forcing meQ to bI choose.Q In one striking example, patients from Program 1 who felt that methadone initially made them drowsy delayed the taking of their medication until after their group so that they could be more alert and participatory. Additionally, in a reflection of their new perspective on their recovery and the value of their program, clients began to speak privately with their counselors regarding individuals in the program who were engaged in activities considered to be antithetical to their recovery. This kind of reporting was something that the staff said that they had never seen before. 8.2. Counselor experience Once the counseling staff overcame their resistance, many benefited from it. Counselors said that they loved it and that it was energizing and exciting. Morale was greatly improved for staff as their enthusiasm grew. bIt gives me a great deal of pleasure to know ITm part of a state of the art methadone treatment program.Q (Program 1 supervisor) An important part of this transformation was their changed perspective on the reinforcements themselves. Instead of seeing them as a bbribe,Q bWe came to see that we need to reward people where rewards in their lives were few and far between. We use the rewards as a clinical tool—not as bribery—but for recognition. The really profound rewards will come later.Q (Program 2 psychologist) The staff and the administrators told us that their morale was improved when they began to see increases in attendance at their groups. Larger groups were easier to run and more gratifying than those with small numbers. In addition, when patients publicly, and sometimes tearfully, acknowledged the counselorTs help, the staff felt a sense of gratitude. bIn the last two award ceremonies, clients said, dI want to thank the staff. . . .T That sounded real good—we feel appreciated.Q (Program 1 counselor) Another counselor from Program 1 said: bNow, thereTs no need for coercion, no more contracts. ThereTs more a
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sense of the clients volunteering. Before we felt like jailers, now weTre looked at differently. . .Q Many staff appeared to take the positive reinforcement approach to heart. Instead of being critical and confronting, they began to affirm and celebrate even small steps in the right direction. In what could be seen as an example of bgradualismQ (Kellogg, 2003), patients were given reinforcements by some counselors as they reduced their drug use and worked towards abstinence. I felt resistant at first. . . But, as it caught on, I began liking giving points to clients. I saw that my client wasnTt using dope, only coke, and ITd say—give him a point! So, now ITm very involved. (Program 4 counselor) Staff members were also inspired when patients who had a long history of being alienated and treatment-resistant responded to the program. In one report, Program 2 staff told the story of a very bshakyQ client with a long history of drug use and treatment failure. When he returned to their program, they gave him a reinforcement every day he came to the clinic for the first month. The patient was completely taken with this; he could not stop talking about the things that they had given him. At the time the staff presented this story, he had been in treatment for 3 months. In Program 3, a man with a chronic alcohol problem cried when he received a McDonaldTs coupon. He said that no one had ever given him anything for working on his recovery. After this, he achieved sobriety for the first time in 8 years. These sorts of bturn aroundsQ were clearly gratifying to the counselors and made them feel that their job was worthwhile. Lastly, relationships among the different staff services (counseling, vocational, nursing) improved. bLast year, the staff were not positive. They were very territorial, and somebody was always waiting to attack this idea. Perhaps they were feeling very threatened. . . Now, the staff are more cohesive.Q (Program 1 Director) bVarious disciplines like vocational rehabilitation and activity therapy have become an integral part of the program. There has been a major acceptance now for vocational counseling and activities, and we now have a dWall of Fame.’ [A bulletin board with pictures of employed patients.]Q (Program 1 Director)
9. Impact on programs
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process included asking patients to attend groups based on a five-session career development program. The program was focused on preparing participants to find, get, and keep a job by helping them discover their interests, values, and strengths, by building their confidence to look for work, and by coaching them in ways to successfully deal with work stressors. The vocational counselors at Program 5 sought to evaluate the effectiveness of this intervention. Because the career counseling series had been in place for a year, they were able to compare the intervention group with an historical control group that did not receive the reinforcements. The results showed that the incentive group was more likely to complete the five 2-hr vocational training modules, and, at 6-month follow-up, they were more likely to be bvocationally engaged,Q which included such activities as having a job, being involved in training, attending school, or being seriously involved in a job search. As noted elsewhere, the leadership at this program was very gratified by these outcomes. Other results came from Program 4, which developed a point system for attending groups and taking recoveryor vocationally-oriented steps. This was tracked over a 10-month period of time. Of the 408 patients who were in the program during that period, 100 received two or more reinforcements. The other 308 did not participate (typically because of work or family responsibilities) or only received one reinforcement. In terms of the number of days per month in which a patient received a reinforcement, the mean was 4.8 in month 1 and 6.8 in month 10. The peak was in month 9 when they averaged 7.6 days. In short, these patients were attending groups or engaging in recoveryoriented behaviors 1 to 2 days per week. Over time, the mean number of reinforcements that each patient received when they did earn one, also increased over time; from 5.2 in month 1 to 12.0 in month 10. The exact meaning of these increases is unclear; they could reflect better group attendance, more recovery-oriented actions, a growing willingness of counselors to use reinforcements to shape positive behavior, or a combination of all of these factors. Looking across all of the programs, the kinds of improvements that staff and administrators reported involved increased attendance at group and individual sessions (including individual and group vocational sessions), more drug-free urine toxicologies, increased completion of vocational training, more jobs, and more attending school.
9.1. Outcomes 9.2. Changes in clinic mood and culture There were two methadone programs in which it was possible to get some quantitative data as to the impact of the approach. While this data was not necessarily collected with the rigor of a formal research project, it is presented here for illustrative purposes. As noted above, Program 5 was particularly focused on the use of incentives to encourage vocational and educational involvement. Part of this
Through this process, some of the clinics began to define themselves differently. One methadone clinic began to truly see itself as a brecovery program,Q not just as a methadone distribution center. They were happy that they were beginning to get a reputation as an methadone treatment program that was bserious about recovery.Q
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Another unexpected, yet welcome, result was the marked decrease in conflict and disruptive behavior in some of the clinics. bThe mood has changed in the last 6 months—there has been less disciplinary action—in fact, no fights at all. There has been no need for escorting people out of the building as has been the case in the past.Q (Program 1 Director) bI think it does strengthen the alliance with the team, not just one counselor. The program has become nurturing.Q (Counselors and Director in Program 3) 9.3. Follow-up At one-year follow-up, the program was generally quite popular among both patients and staff. The Coordinator of Vocational Services at Program 5 noted: bThere are three clinics here and 700 patients. It will take us some more time to fully implement the contingency management program as desired. We are on the right track, though, and we saw some unbelievable results in our vocational groups.Q
10. Perspectives and limitations This intervention, differed from some of the classic contingency management protocols (i.e., Higgins et al., 2002; Petry et al., 2000; Silverman et al., 1996) in two important ways. The first was that this was not an add-on to an existing program; it became the centerpiece for all of the psychosocial treatments. The second important difference was that the reinforcement system itself was, for the most part, devised and run by the counselors and line staff. They saw, first hand, the power of this kind of behavioral technology, and they directly reaped the benefits of it in the form of greater professional success. We are greatly aware of the limitations of this work. Clearly, it is more of a story than a study. Nonetheless, something remarkable appears to have happened in these clinics that can be a source of inspiration to other programs that are considering adoption of a contingency management approach. Looking back on this experience, it seems that a foundation for success was established through the efforts that HHC and OASAS made to improve treatment. Contingency management then acted as a catalyst that connected the patients to the program and animated the whole system. In addition, the successes involved the coming together of the forces discussed above. There was funding, a focus on improving treatment outcomes for a large portion of the patient base served by HHC, a scientific and clinical paradigm and framework, leadership support on-site and on the executive level, and the creativity, enthusiasm and interest of staff. Perhaps it would also be fair to say that the sixth
force was the appreciation for, and the embracing of, the initiative by the patients.
Acknowledgments Portions of the paper were presented as talks on December 5, 2003, at the 14th Annual American Academy of Addiction Psychiatry Meeting in New Orleans, LA, on January 26, 2004 at the 7th Annual Conference of the Alcoholism and Substance Abuse Providers of New York State held in New York City, on July 12, 2004 at the Translating Research into Practice Conference in Washington, DC, and at the Science in the Trenches conference in New York, June 21, 2004. It was also presented as a poster at The College on Problems of Drug Dependence, 66th Annual Scientific Meeting, San Juan, Puerto Rico, on June 14, 2004. The authors would like to thank the following individuals for their assistance in the development and implementation of this project: Michael Norman Haynes and Antonio Webb in the HHC Office of Behavioral Health; Ludwig Hauser and the staff at the Bellevue Hospital Methadone Treatment Program; Jamie Rosario and the staff at the Coney Island Chemical Dependency Treatment Program; Martin Gaffney and the staff at the Elmhurst Hospital Methadone Treatment Program; Aisha Muhammad, Curtis Saunders, and the staff at the Harlem Hospital Methadone Treatment Program; and Janet Aiyeku, Dayo Alalade, and the staff at the Kings County Hospital Methadone Treatment Program. We would also like to thank Elizabeth Oosterhuis for her assistance. Scott KelloggTs efforts were supported, in part, by NIDA grants P60-DA05130 and DA 13046-04. He would also like to thank John Rotrosen for his assistance and support.
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