Substance abuse treatment providers' beliefs and objections ...

Drug and Alcohol Dependence 85 (2006) 19–27

Substance abuse treatment providers’ beliefs and objections regarding contingency management: Implications for dissemination Kimberly C. Kirby a,∗ , Lois A. Benishek a,∗ , Karen Leggett Dugosh a , MaryLouise E. Kerwin b a

Treatment Research Institute, 600 Public Ledger Building, 150 S. Independence Mall West, Philadelphia, PA 19106, United States b Rowan University, Glassboro, NJ 08028, United States Received 9 January 2006; received in revised form 9 March 2006; accepted 11 March 2006

Abstract Contingency management (CM) interventions are among the most effective methods for initiating drug abstinence, but they infrequently have been adopted by community drug and alcohol treatment programs. The primary purpose of this investigation was to determine the prevalence of specific beliefs that community treatment providers hold regarding contingency management interventions. We surveyed 383 treatment providers from three geographical areas of the United States regarding moral or ethical objections, negative side effects, practicality, limitations and positive opinions regarding tangible and social CM interventions. Results indicate that positive beliefs were surprisingly prevalent, with providers agreeing with an average of 67% of the positive statements regarding CM using tangible incentives and 54% indicating that they would be in favor of adding a tangible CM intervention to their treatment program. The most prevalent objections to incentive programs were that they cost too much, fail to address the underlying problems of addiction, and do not address multiple behaviors. Social incentives were viewed more favorably than tangible incentives and both were viewed more positively by providers who were supervisors, had advanced degrees, had more addictions experience, and had previous experience with tangible incentives. These findings have implications for improving the dissemination of this empirically-supported treatment. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Contingency management; Drug abuse treatment; Evidence-based practice; Treatment provider survey

1. Introduction Contingency management (CM) interventions, also known as incentive-based interventions, have been consistently shown to increase both treatment engagement and drug abstinence across a range of drug abusing populations (see Higgins et al., 2002, 2004). Of 55 studies using contingency management interventions with substance abusing and dependent populations, 47 (85%) report significant changes in at least one of the targeted behaviors (Higgins et al., 2004). Furthermore, independent reviews of empirically-supported treatments for psychological disorders have identified CM and other reinforcement-based interventions (i.e., reinforcement, community reinforcement) as efficacious or probably efficacious for treating alcohol, marijuana, cocaine, and opiate abuse and dependence (Chambless and Ollendick, 2001; McGovern and Carroll, 2003).

∗

Corresponding authors. USA. Tel.: +1 215 399 0980; fax: +1 215 399 0987. E-mail address: [email protected] (K.C. Kirby).

0376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2006.03.010

Despite the growing body of research supporting the efficacy of CM procedures, they are not readily adopted into general clinical practice. McGovern et al. (2004) noted that treatment providers reported that CM interventions were used in their programs only 11–25% of the time. Among counselors, 9% reported that they were just beginning to use CM techniques. Willenbring et al. (2004) identified a similar pattern of responses among Veterans Administration program administrators; only 30% indicated that they used CM on a moderate or high frequency basis. Similarly, in a survey of treatment providers in California, only 27% reported any use of CM interventions (Herbeck et al., 2005). A number of researchers have suggested reasons why incentives programs are not being implemented in community treatment settings (Kirby et al., 1999; McGovern et al., 2004; Petry and Simcic, 2002). These reasons include the possibility that incentive programs are viewed by treatment providers as being too costly and labor intensive; too difficult to implement, and a poor fit with what clinicians are already doing; that treatment providers are not adequately trained to administer CM

20

K.C. Kirby et al. / Drug and Alcohol Dependence 85 (2006) 19–27

interventions; or that the political and philosophical opinions held by treatment providers create barriers to using incentive programs with their clients (e.g., the view that incentives are a bribe). Our review of the literature identified only one study that empirically documented reasons substance abuse counselors and administrators object to or fail to use CM. Willenbring et al. (2004) identified Veterans Administration leaders’ barriers to implementing CM as a lack of knowledge and skills necessary to implement CM (57.5%), lack of staff time (54.8%), and low demand for CM (50.9%). However, it is possible that the responses of Willenburg et al.’s sample are not representative of community-based treatment providers. Participants were typically mid-career men (70.5%); more than half had earned a degree at the M.D. or Ph.D. level, a majority had participated in research, 20% had been a principal investigator on a research grant, and most programs were affiliated with medical schools. In contrast, McGovern et al. (2004) surveyed community treatment programs that relied primarily on state funding via federal block grant mechanisms. Their sample was predominately female, the modal level of education was at the master’s degree level, and nearly half (48%) of the counselors in this sample reported that they were not familiar with CM interventions. Similarly, Herbeck et al. (2005) reported that 43% of the program directors and 32% of program staff that they surveyed did not know anything about the effectiveness of CM. If researchers are to facilitate the adoption of efficacious interventions into community-based treatment programs, it would be helpful to better understand the specific beliefs and objections that community treatment providers hold regarding those interventions. Understanding objections may be particularly important in guiding researchers to develop new CM interventions that are more community-friendly and, therefore, likely to be more easily disseminated. It would also be helpful to know the prevalence of specific beliefs and objections so that those disseminating CM could be better prepared to address the most prevalent beliefs and be able to recognize objections that are less likely to be held by the majority of treatment providers. Knowing whether beliefs and objections are general to all incentive programs or apply only to incentive programs that use specific types of reinforcers could also be useful in facilitating dissemination. Reinforcers frequently have been categorized into different types (e.g., Hall, 1971; Cooper et al., 1987). For example, we focused on two broad categories of reinforcers: tangible and social. We define tangible incentives as goods or services (e.g., gift certificates or retail items ranging in value from $1 to $100) that are given to clients who exhibit an agreed-upon behavior such as providing a drug-free urine sample or achieving some other treatment goal. Social incentives are defined as those that provide social recognition (e.g., printed certificates; verbal complements) or special privileges (e.g., a preferred methadone medication time; a reduction in treatment requirements) to clients who provide a drug-free urine sample or achieve their treatment goals (cf. Hall, 1971; Cooper et al., 1987). Social incentives might also be arranged by teaching important people in the client’s life how to deal with the

drug use and be supportive of accomplishments. Differences in treatment providers’ perceptions of these two types of incentives could provide clues to understanding whether objections are specific to the use of tangible “payments” for good behavior or extend to the systematic use of consequences in general. Finally, in planning for the dissemination of CM into community treatment programs, it might be helpful to know if beliefs and objections differ depending on the characteristics of treatment providers, such as their job position, education, recovery status, and experience in addictions treatment generally, and with incentive interventions in particular. There is some indication that treatment providers’ characteristics are, in fact, associated with attitudinal differences toward other types of treatment interventions. For example, research suggests that men are more like to view relapse prevention more positively than their female counterparts (Ball et al., 2002), masters-level counselors are less supportive of 12-step approaches than counselors without an advanced degree (Ball et al., 2002), counselors with lower levels of education are more likely to endorse a larger number of counseling techniques than their more highly educated counterparts (St˝offelmayr et al., 1999), and counselors who identify themselves as being “in recovery” hold more favorable attitudes toward 12-step (Ball et al., 2002) and more eclectic substance abuse treatment approaches (Humphreys et al., 1996) relative to those who do not self-identify as being “in recovery”. This investigation addressed all four of these issues by asking: (1) What are the specific beliefs that community treatment providers hold regarding CM and what is the prevalence of these beliefs? (2) Are there differences in beliefs and objections between tangible incentive and social incentive programs? (3) Are there differences in beliefs and objections depending on the characteristics of treatment providers? 2. Method 2.1. Participants and procedures Participants (n = 383) consisted of counseling staff (n = 253), supervisors (n = 49), and medical or clinical support staff (n = 70) employed at substance abuse treatment programs located in the Delaware Valley (i.e., Eastern Pennsylvania, Southern New Jersey, Delaware), a Midwestern state, and a Southern state. Participants were recruited from their treatment programs or from Addiction Severity Index (ASI) trainings conducted for state providers by a member of the research team. We approached those recruited from treatment programs during a regular staff meeting so that all participants were contacted in a group setting. After introducing the study and obtaining informed consent, participants answered five descriptive questions and then completed a brief survey. Participants recruited from treatment programs were paid $10 for participating. The names of the individuals attending the ASI trainings were entered into a drawing to win a $30 gift certificate. All procedures were reviewed and approved by the Treatment Research Institute IRB. Refusals to participate were rare. Table 1 provides the descriptive information for this sample.

2.2. Provider survey of incentives (PSI) The PSI is a 44-item survey that was developed to assess substance abuse treatment providers’ attitudes toward CM incentives programs. Items were developed from 10 treatment providers’ responses provided during an open-ended in-depth interview. Based on these responses, items concerning beliefs and objections or barriers to implementation were developed by two experts in CM and an expert in instrument design. Items were retained, eliminated or modified

K.C. Kirby et al. / Drug and Alcohol Dependence 85 (2006) 19–27 Table 1 Characteristics of treatment providers Variable

21

3. Results N

%

Position in program

Counselor Supervisor Other

253 49 70

67 13 18

Education

High school/GED/AAa BA/BS Advanced degree Nursing degree

46 116 159 21

12 30 42 5

Recovery status

In recovery Not in recovery

92 282

24 74

Years in addictions field

2 or fewer years >2 to 7 years >7 to 12 years >12 years

84 93 84 109

22 24 22 28

Prior experience with incentives

Prior experience tangible Prior experience social only No prior experience

65 40 264

17 10 69

Note: percentages are based on the total sample of 383 respondents. The percentages may not sum to 100 due to missing data. a Associates’ degree.

after piloting the survey with 250 community treatment providers. The majority of the survey items can be categorized into five basic themes: (1) limitations of incentive programs (e.g., do not address underlying issues; will only last as long as incentives are given); (2) moral or ethical objections (e.g., it is not right to give an incentive to someone for fulfilling one treatment goal if they are not fulfilling other treatment goals; incentives are a bribe); (3) negative side effects (e.g., jealousy or arguments among clients, damage to the treatment process); (4) impracticality (e.g., too expensive, too labor intensive, require frequent urinalysis); and (5) positive opinions regarding incentives (e.g., incentives help the client become abstinent). Participants indicated degree of agreement with each item on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: neutral; 4: agree; 5: strongly agree). Twenty-eight of the 44 items assess beliefs about both tangible and social incentives. The instructions for the survey provide definitions of tangible and social incentive programs that are consistent with the definitions we provided in the introduction. Participants are asked to indicate degree of agreement with each of these items twice, once for use of tangible incentives and once for use of social incentives. In addition to the 28 parallel items, there are 10 items that pertain uniquely to tangible incentive programs. Six of these 10 items focus on affordability or a cost-benefit evaluation of different levels of financial cost (i.e., $10, $50, or $150 per client per month). The remaining four unique tangible items address negative or positive effects specific to tangible incentives (e.g., clients who sell tangible incentives will use the money to continue their drug use; tangible incentives are worthwhile because they get clients in the door for treatment). Finally, beyond the 28 parallel items and the 10 unique to tangible items, there are four items that are unique to social incentives (e.g., structured praise is not necessary because counselors already praise accomplishments), and two general questions that address belief in the 12-step approach and its compatibility with incentive programs. Summary scores for tangible and social incentives were based on the 28 parallel items only. They were calculated by reverse-scoring scale items associated with negative opinions so that higher ratings on the Likert scale uniformly indicated more positive beliefs about incentive programs. Six of the 28 parallel items performed poorly in a factor analyses for either the tangible or social subscale and were removed from both subscale calculations creating two identical 22-item scales. Both subscales demonstrated good internal consistency. The coefficient alpha estimate for the tangible subscale was .92, and the average item-total correlation was .56 (range = .39–.75). The coefficient alpha for the social subscale was .90, and the average item-total correlation was .52 (range = .39–.70).

Percentages of participants agreeing (4) or strongly agreeing (5) with individual items were calculated for descriptive purposes. Most of the participants (94.5% for tangible and 95.8% for social) agreed or strongly agreed with at least one positive statement about tangible and social incentive programs, with an average of 5.8 (S.D. = 2.8) and 6.4 (S.D. = 2.7) positive statements endorsed per provider, respectively. A similar proportion (92.7% tangible; 88.2% social) of the treatment providers surveyed agreed or strongly agreed with at least one objection or limitation regarding tangible and social incentive programs, with an average of 5.2 (S.D. = 4.2) and 4.2 (S.D. = 3.5) objections per treatment provider, respectively. 3.1. Tangible versus social incentives A dependent t-test was used to compare PSI tangible and social subscales. Among providers for whom both tangible and social subscale scores could be computed (n = 350), significantly more positive beliefs were observed for social (Ms = 3.55, S.D. = .51) than for tangible incentives (Mt = 3.38, S.D. = .56, t(349) = 10.17, p < .0001). Despite this statistical difference, there was little actual difference between means (Ms − Mt = .17). 3.2. Parallel items Percentages of participants agreeing or strongly agreeing with the 28 items that were parallel across tangible and social incentive programs are presented in Table 2. These items are presented in descending order of the tangible items. 3.2.1. Positive opinions. Percentages of participants agreeing with positive items are presented at the top of Table 2. Overall, there were greater proportions of participants agreeing with statements reflecting positive opinions than with statements reflecting objections and concerns about limitations (Table 2, second section). Every positive statement was endorsed by at least 45% of the treatment providers, whereas only the first two objections and limitations were endorsed to this degree. The six highest ranked tangible items were also among the six highest ranked social items. Just over three-quarters of the treatment providers indicated that they would be in favor of adding social incentives to their treatment program, however only slightly more than half endorsed the addition of tangible incentives. Statements that were among the most highly endorsed for both tangible and social incentives included that any source of abstinence motivation, not just internal motivation, is a good thing for treatment; that incentives are useful if they reward clients for fulfilling treatment goals other than just providing a clean urine; and that incentives are more likely to have positive effects than negative effects on the client. 3.2.2. Objections and limitations. Overall, Table 2 reveals similar ratings of objections and limitations for tangible and social incentive programs. All of the objections and limitations regarding tangible incentives and most regarding social incentives

22


Table 2 Percentage of participants agreeing with statements Parallel items Positive opinions (nine items) Any source of abstinence motivation, not just internal motivation, is a good thing for treatment Incentives are useful if they reward clients for fulfilling treatment goals other than just providing a clean urine, such as for regular attendancea Incentives are more likely to have positive effects on the client than to have negative effects An advantage of incentive programs is that they focus on what is good in the client’s behavior (e.g., being abstinent), not what went wrong in recovery Incentives can be useful whether or not they address the underlying issues of addiction Overall, I would be in favor of adding an incentive program to my treatment program Incentives help the client achieve sobriety, allowing the counselor to focus on helping them make other life changes Giving incentives for drug-free urine samples helps the client become abstinenta Overall, incentives are good for the client/counselor relationship Objections and limitations (19 items) Incentives do not address the underlying issues of addictiona It would not be right to give an incentive to clients for being clean when they are not fulfilling other treatment goals, such as attending a group It would not be right to give an incentive for goals such as attendance if they are not testing drug negative Incentives will cause jealousy among clients who do not get thema If a client is abstinent just to get the incentive, it could hurt the treatment process Incentives are a bribe Incentive programs that require close tracking of client behavior are too labor intensive to incorporate into our programa Incentive programs that require urinalysis at least once a week are not practical because most programs do not take weekly urines on all clientsa Incentives will stop the client from seeing beyond the external reward and prevent them from realizing their internal motivation A problem with incentives is that abstinence will only last for as long as incentives are given Incentive programs are not consistent with my philosophy of treatment Many clients will see rewards for abstinence as cheesy or artificial Incentives are not useful for short-term treatments (e.g., 1 month or less) There are enough rewards in being clean; incentives are not necessary Giving incentives for treatment attendance will not improve attendance Incentives are just not right because they are rewarding the client for what he/she should be doing in the first place Overall, incentives have negative effects on the client/counselor relationship Incentives are more likely to have negative than they are to have positive effects on clients Consistently providing the client with incentives is likely to push the client back into denial a

Tangible

Social

73.6 67.1

74.2 71.3

62.9 61.6

70.5 63.2

59.0 54.0 50.1 46.0 44.9

61.9 77.0 57.4 46.7 57.7

52.2 50.4

47.0 44.6

42.3 39.2 33.2 29.8 29.5 27.7

39.4 31.9 26.6 18.5 28.2 27.9

23.5 22.2 22.2 21.9 17.5 16.4 15.9 15.7 12.3 11.7 11.5

13.3 15.4 14.4 18.8 13.6 13.1 15.7 10.7 7.0 5.7 7.3

Indicates one of the six items that performed poorly in a factor analyses for either the tangible or social subscale and were removed from both subscale calculations.

were endorsed by at least 10% of the treatment providers. The top four objections and limitations were the same across tangible and social incentive programs and were endorsed by at least 30% of the participants. These objections and limitations covered three concerns: (a) incentives do not address the underlying issues of addiction, (b) it is not right to give an incentive for one behavior when clients are not fulfilling other treatment expectations, and (c) incentives will cause jealousy among clients. Given that the most frequently endorsed concern was that incentives do not address the underlying issues of addiction, it is interesting to note that about 60% of the treatment providers agreed with the statement that incentives can be useful whether or not they address the underlying issues of addiction. Among the subgroup of treatment providers who believed that tangible incentives do not address the underlying issues of addiction (n = 200), 62% indicated that incentives were useful anyway, while only 17.5% disagreed or strongly disagreed that they were still useful. The pattern was similar for social incentives, among providers who believed incentives did not address the underlying issues (n = 180), 66.1% believed they were still useful, while only 15% did not.

Generally, the remaining items were rated similarly (differences 10%) for two items: “incentives are a bribe” and “incentives will stop the client from seeing beyond the external reward and prevent them from realizing their internal motivation”. 3.3. Unique tangible incentive items Percentages of participants agreeing with the six unique tangible items that addressed issues of the cost of the intervention are presented in Fig. 1. As the cost of the tangible incentives per client per month increased, more treatment providers indicated that their programs could not afford the added costs (F(2,746) = 123.04, p < .0001) and fewer believed the cost was worthwhile (F(2, 724) = 6.56, p = .001). Three of the remaining four unique tangible items addressed objections and limitations of tangible incentive programs. Approximately one-third (35.5%) of the treatment providers believed that if you give tangible reinforcers to the clients who have earned them, but not to others, it would result in clients


23

Table 3 ANOVA resultsa F

p

fb

Analysis

Effect

d.f.

Position

Position Type Position × type

2, 302 1, 302 2, 302

5.93 35.27 1.43

.003 .18