What Is It, and Why Should We Do It?
Motivational incentives is a therapy that has been shown in evidence-based research to be an effective strategy in the treatment of substance use disorders. Also known as contingency management, this method has found great success in alcohol abuse treatment. In a 1975 study, Miller found that providing tangible reinforcers, contingent on negative breath-alcohol tests, effectively reduced public inebriation. Studies during the 1980s (Bringham et al. 1981, Peniston 1988) reported positive outcomes of using reinforcement to encourage abstinence among adolescent alcohol abusers and alcohol-abusing schizophrenics. These and other studies have been based on the famous work of B.F. Skinner involving operant conditioning - behaviors that are rewarded are repeated. Throughout our lives, we receive rewards for behavior or performance, such as good grades in school, bonuses and incentives in the workplace, or increased commissions in sales positions. The behaviors associated with positive outcomes (like increased profits for an organization) are rewarded. Conversely, behaviors that are detrimental either to ourselves or an organization are punished. For example, when a child touches a hot stove, the child learns the unpleasant consequences (pain) and does not repeat the behavior. Repeated tardiness at school or work typically results in a phone call to the parents, or termination of employment.
Drugs of abuse have inherent rewards to the user - the rewards are not always pleasant, but they are immediate and powerful reinforcers. While it is known, even by people actively engaged in the risky use of substances, that abstinence brings its own rewards (healthier lifestyle, employment and education opportunities, maintaining positive relationships), the "pull" of dependence and its immediate rewards continues. In the process of becoming abstinent, it typically takes a long time before any rewards are experienced.
Skeptics of motivational incentives have noted that patients should not be "bribed" to engage in treatment, and that they will eventually seek treatment when they "hit bottom." Incentives are a way of motivating patients toward healthier lifestyles without having to risk total annihilation first. There already exist incentives to not use substances: possible arrest if you are using an illegal substance, loss of job if you are tested positive, or arguments with partners about the use. Notice, however, that these incentives are all punishments for using rather than rewards for not using. This difference is important and operates in everyone's life. Why is it that most people so seldom drive the speed limit or slower? There is an incentive to not speed: if you speed and you get caught, you will have to pay a fine or go to traffic school. The reason why this incentive has limited effect on most drivers is that you can speed many times, if not most times, and not be caught. The incentive is only occasionally applied. Why is it that most people so seldom floss their teeth? You probably know that it is relevant for your dental hygiene and you do another behavior for that reason: brush your teeth. You might floss the night before seeing the dentist. When you were a child, brushing probably held less value for you than when you became older. As an adult who kisses, you notice that brushing typically has an immediate and consistent reward of your mouth feeling fresh. Flossing may not have much immediate or noticeable reward.
Substances have built-in, immediate rewards. People use drugs because they like some things about the effects. In that sense, drugs achieve a desired effect. Even after dependency has developed and the pleasant experiences from using have evaporated, the drug use still relieves the unpleasant withdrawal symptoms.
Here are some reasons drinkers have reported for cutting down their drinking (Strecher, et al. 1994):
Notice that most of these reasons are reasonable and logical but they are also somewhat symbolic and even distant in the future. Flossing is likely to improve health and yet most of us don't do it even knowing that reason. Flossing would be a good example for our children and yet most of us don't do it. Our dentist recommends flossing and yet most of us still don't do it.
Consider the reasons these drinkers had for NOT cutting down on drinking:
Notice that these reasons are more immediate and more tangible. These reasons often win out over the reasons to cut down drinking.
Arranging an immediate and tangible reward for engaging in the health-promoting alternative often helps a client resolve his ambivalence about doing the health-promoting alternative. What if every time you drove the speed limit for ten miles you received a reward? Would you be more likely to drive the speed limit? What if you were paid a dime? Maybe a dime is not enough. The reward would have to be given often enough and be large enough to compete with the reasons you have for speeding. Consider also the problem of how to actually observe if you are driving the speed limit. Self-report is probably not reliable enough, and distortion is likely to occur: "I'm here to collect my $10 reward. I am telling you that I drove the speed limit all last week when I drove to and from work which was a hundred miles."
Principles of Motivational Incentives
The success of motivational incentives depends greatly on several principles. First, clinicians must arrange for regular and consistent drug use screening to ensure that the patient's use of the targeted substance is readily detected. Ideally, observed urine screening should occur most frequently during initial treatment. Results should be available immediately and on site so that the appropriate reinforcer can be administered as closely as possible to the testing and the last day or two of abstaining.. Consistent and immediate reinforcement results in the greatest motivation for behavior change. A clinician's initial instinct may be to reward patients only when they demonstrate complete abstinence. The greatest benefit in motivational incentives is achieved in rewarding the small steps that lead to the desired behavior. Targeting a single drug at a time helps the client achieve initial success that may promote further motivation to abstain from secondary drugs as well.
The second principle of motivational incentives is that reinforcers (prizes, vouchers, clinic privileges) should be agreed upon by both the clinician and the client as something that will motivate the client. There is little motivation in receiving something that you don't want or will not be of any benefit to you. Choose prizes or incentives that are meaningful to your client population, and communicate ahead of time that this will be the result of achieving the desired behavior (e.g., abstinence, treatment attendance, steps toward employment goals). Behaviors must be identified that can be quantified objectively. These can include behaviors such as acting appropriately in a group session, taking steps toward improving interpersonal difficulties, meeting regularly with the parole officer as mandated, or actively pursuing employment. Clients can receive incentives for verification of steps in these goals, such as providing receipts. Optimally, clinicians should conduct a needs assessment with their client to determine appropriate goal-reinforcing activities. One goal may be to acquire gainful employment. Activities that reinforce this final goal might include circling jobs in the newspaper, making three phone calls to employers, attending two job interviews. Rather than simply rewarding a final goal outcome (e.g., gaining employment), clients should be encouraged at various steps along the way, such as compiling a resume or making a list of employment options from the newspaper classified advertising. In other words, you can give a client a token, a clinic privilege, or a gift certificate whenever she or he tests negative for drugs or displays a behavior that you want to reinforce.
Vouchers or cash systems tend to be the most expensive, averaging about $600 per client with each client able to earn up to $1000 worth of goods during treatment. Additional costs include the staff time to purchase items to exchange for vouchers, transportation costs to obtain items, and the cost of the vouchers themselves. Be aware, however, that motivational procedures lose their effectiveness when the magnitude of the reinforcement gets too low. Another incentive system is to allow clients to draw from a fishbowl for prizes of varying costs, with the chances of winning inversely related to prize costs. The average cost per client is under $200, and some prizes can be obtained through donations.
Also important is establishing that the clinician will withhold the designated incentives when substance use disorder is detected. Again, this withholding of incentives must be demonstrated consistently and immediately. Clinicians can work together with other systems in which the patient is involved, such as law enforcement or the family, to report advances in treatment as well as setbacks. This gives the client the opportunity to celebrate small steps to recovery along with the support and recognition of other important individuals outside of the treatment center. Important variables are the frequency of occurrence of the target behavior, the monitoring schedule, and the delivery of the reinforcement.
Finally, the clinician should assist the patient in establishing alternate and healthier activities to compete with the reinforcement derived from the alcohol or other drug. It is important to help your patients experience the inherent rewards of an alcohol- or drug-free lifestyle to overcome the previous chemical rewards provided by the substance. Without an acceptable or better substitute, patients will likely revert to the behavior that provided the greatest reward for them.
Point-of-Care Screening
Choosing the appropriate point-of-care screening test depends on several factors. In order for the incentive to be appropriately applied, the screening results must be immediately available. There are several commercially available products that screen for drugs of abuse at varying cost and complexity.
There are different point-of-care testing methods available for on-site drug testing, with the most popular being urine and saliva testing. With any on-site testing method, it is essential that they be used with a full understanding of the limitations of the specific test device with respect to sensitivity and specificity. In light of the limitations of on-site testing methods, it is recommended that:
- All such devices should be initially evaluated by professional laboratory staff who are experienced in the field of drugs-of-abuse screening.
- Once a device is evaluated and reviewed in a controlled laboratory setting, a cost-benefit analysis should be performed to determine whether the use of that device is cost-effective, taking into account both staff time and consumables.
- Adequate training must be given to all those who will use the screening devices in outpatient clinical areas. Such training must ensure that operators fully understand the method and its limitations and that they are responsible for any errors that may arise in interpretation of results.
- Quality control and quality assurance must be covered in addition to appropriate storage, maintenance, and calibration of any screening device used. Records of these procedures may have to be kept for a specified time period in order to defend any action brought against the person performing the drug testing. Check the regulations in your state. (George & Braithwaite, 2002)
Advantages and disadvantages of point-of-care testing for drugs of abuse: (George & Braithwaite, 2002)
Advantages
- Rapid turnaround of results because screening tests can be performed on site
- Rapid clinical action with patient actually being screened by drug worker or general practitioner
- Confidentiality of individuals assured because specimens do not need to be sent away for analysis
- Local control of all drug-testing issues
- Chain of custody is not an issue because testing is performed on site
- The person being screened can see the test being performed
Disadvantages
- Relatively high cost especially when using individual tests to create a multiple drug screen
- Limited specificity of NPT devices, especially for amphetamines and opiates
- Poor or nonexistent quality control of the testing devices
- Poor recordkeeping after testing with NPT devices
- Interpretation may be a problem because of the lack of specificity of the NPT devices
- Subjective interpretation of occasional poor end-point coloration
- Positive screening results may need to be confirmed by an outside laboratory
- Possible limited ability to detect adulteration or falsification of specimens (e.g., diluted or adulterated samples)
Advantages and disadvantages of saliva monitoring for drugs of abuse: (George & Braithwaite, 2002)
Advantages
- A relatively noninvasive method with specimen collection that can be observed without embarrassment to the person under investigation
- Little chance of sample adulteration because the whole sample collection procedure can be supervised
- Commercial screening devices are available for saliva monitoring that have been evaluated by some police forces for roadside drug screening use
- There is less chance of specimen collection problems or specimen adulteration than with urine
Disadvantages
- Small specimen volumes restricting the number of analyses that can be performed
- Contamination of the mouth may affect drug-screening results
- Adulteration feasible as a result of oral contamination
- Difficult to collect from those abusing stimulants such as amphetamines and Ecstasy
- Routine screening procedures not always applicable to screening saliva
- Low concentrations make detection difficult and necessitate the use of expensive equipment
- Small sample volumes make confirmation of screening results difficult
- More expensive than urine screening.
It is important to know how long different drugs stay in the system in order to appropriately reward abstinence. For instance, if the goal is to be abstinent from cocaine and you are performing testing three times a week, the first test may indicate drug use up to five days ago. In order to establish a trusting relationship, it should be made clear at the beginning of treatment that the screening result is the sole determiner of the incentive. Client-reported abstinence can be confirmed with a repeat test within a day or two, and the client should be encouraged and facilitated to remain abstinent.
How long do drugs stay in the system?
| Amphetamines |
2-6 days |
| Barbiturates |
3-8 days |
| Benzodiazepines |
2-14 days |
| Cannabis |
14-30 days |
| Cocaine |
2-5 days |
| Methadone |
2-8 days |
| Methamphetamines |
2-6 days |
| Opiates |
2-5 days |
| PCP |
3-8 days |
| Tricyclic Antidepressants |
10 days |
Evidence of Success
Research has shown that motivational incentives reinforce not only abstinence, but other treatment goals as well. Patients stay in treatment longer when they are motivated to attend sessions, giving the treatment protocol a better opportunity to engage the patient. In one program, only 40% of patients receiving standard treatment completed the 24-week treatment. Seventy-five percent of those patients receiving vouchers for attending sessions remained in treatment for 24 weeks.
(Higgins, et al. 1994)
Over time, patients are transitioned from the use of more contrived reinforcers (e.g., vouchers, prizes, privileges in the clinic) to more naturally occurring reinforcers (e.g., obtaining and maintaining employment, improved family relationships). As the natural reinforcers are created more reliably by the patient in his or her life, alcohol and other drugs become a less attractive option.
The Health and Hospitals Corporation in New York instituted a motivational incentives program in their clinics and reported the following outcomes:
- The patients were excited about the program from the start. They began to show increases in self-esteem, improvements in appearance and self-care, and a more goal-oriented perspective. There were a number of stories concerning the initiation of a family reconciliation process that took place when patients shared their treatment success with estranged relatives.
- Some counselors believed that the patients began to take on a greater sense of responsibility for their recovery; they went from "You are forcing me" to "I choose."
- The process of receiving a reinforcement or prize was quite powerful, and the staff reported a number of instances in which patients burst into tears when they were acknowledged in a positive way.
- The counseling staff were initially quite resistant. However, when they saw both the enthusiastic response and the positive changes in their patients, they typically embraced the approach in a dynamic and creative way. Over time, they became more comfortable with the use of reinforcements and some changed their initially negative perspective to one that was more positive. Instead of seeing reinforcements as some form of "bribery," they began to understand that they were effective tools for behavioral change.
References
Accentuate the Positive: Vouchers help drug abusers stay in treatment. APA Online: Psychology Matters. http://www.psychologymatters.org/higgins.html October 21, 2004.
George, Stephen and Robin A. Braithwaite. Use of On-Site Testing for Drugs of Abuse. Clinical Chemistry. 2002; 48:1639-1646.
Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.E.; Donham, R.; and Badger, G.J., (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archieves of General Psychiatry, 51(7), 568-576.
Higgins, S.T. and Nancy M. Petry. Contingency Management: Incentives for Sobriety. Alcohol Research & Health. 23:2 (1999) 122-127.
Jen Tidey, PhD. Contingency management interventions: Enhancing motivation through incentives. The Brown Digest of Addiction Theory and Application. 23:2(2004) 8.
M.P. McGovern, et al. Journal of Substance Abuse Treatment. 26 (2004) 305-312.
Petry, N. (2000). A comprehensive guide to the application of contingency management procedures in clinical settings. Drug and Alcohol Dependence, 58, 9 - 25.
Petry, Nancy M. A clinician's guide for implementing contingency management programs. A guideline developed for the Behavioral Health Recovery Management project. Illinois Department of Human Services' Office of Alcoholism and Substance Abuse.
Strecher, V., Kobrin, S., Kreuter, M., Roodhouse, K., & Farrell,D. (1994). Opportunities for alcohol screening and counseling in primary care. Journal of Family Practice, 39, 26-32.