Download Keeping It Positive: Bringing Contingency Management to New York

Keeping It Positive:
Bringing Contingency Management
To New York City
Scott Kellogg, PhD
New York University/
New York Node
What Is
Contingency
Management?
B. F. Skinner, PhD
3
Contingency Management





Developed out of Skinner’s Operant Conditioning
model
Typically involves the use of positive reinforcements to
change behavior
First applied to problems with alcoholism in the late
1960’s
Used in the treatment of drug addiction beginning in
the early 1970’s
One of the first protocols that were considered for
adoption by the NIDA Clinical Trials Network
Contingency Management

In addiction treatment centers, CM has been
primarily used to:
 Reduce or eliminate drug use
 Increase group attendance
 Facilitate compliance with medical treatment
 Reinforce treatment goal attainment
The Early Days of the CTN
http://images-eu.amazon.com/images/P/B0002PC31M.02.LZZZZZZZ.jpg
CTN Site Map – 2000
6 Nodes
New York Node


The New York Node joined the Clinical Trials
Network in 2000
During the following months
 There would be at least two conflictual
Steering Committee meetings
 Then the CM protocol was accepted
Moving Forward

The protocol then went into its development
stage where it was renamed ….
Motivational Incentives for
Enhanced Drug Abuse Recovery
(MIEDAR)


Maxine Stitzer, PhD
Nancy Petry, PhD
MIEDAR Protocol
Overview Materials
Sample Collection
Twice Weekly
How Motivational Incentives
Could Work For You
Patient
Provides Clean
Urine
Patient Earns
Incentive
Patient
Provides More
Clean Urines
How do we expect this to benefit
clients and counselors?
• Better outcomes for your clients
• More time to do what you like to do
and what you do best in therapy
sessions
New York Node Team





John Rotrosen, MD – New York Node
Principle Investigator
Scott Kellogg, PhD – New York Node
MIEDAR Principle Investigator
Marion Schwartz, CSW – Project Director
Agatha Kulaga, MSW – Research Assistant
Caroline Woo – Research Assistant
New York MIEDAR Clinics
New York



Two methadone maintenance programs joined the
study:
Lower Eastside Service Center
 Under the leadership of Joe Krasnansky, CSW
Greenwich House MMTP
 Under the leadership of Lolita Silva-Vasquez,
CSW
Up and Running



By late 2001, the protocol was up and running in
New York
The Node then turned its attention to the
creation of the second Blending Conference
Which was scheduled for March, 2002
Meanwhile…
New York City Health
and Hospitals Corporation


The largest provider of addiction treatment in the
United States
Runs methadone programs in five major hospitals
 Bellevue Hospital
 Kings County Hospital
 Elmhurst Hospital
 Lincoln Hospital
 Metropolitan Hospital
Mayor Rudolph Giuliani
http://www.umich.edu/~ac213/student_projects07/global/rudygiuliani.jpg
Giuliani Orders 5 City Hospitals To
Wean Addicts Off Methadone
By RACHEL L. SWARNS
Published: August 15, 1998, New York Times
Mayor Rudy Giuliani – Summer 1998



Mayor Giuliani shocked the world of methadone
treatment
Voiced his concern that methadone patients
were not being empowered to find employment
Proposed a plan in which opiate-addicted
individuals would only be able to get threemonths of treatment
 At City-run methadone facilities
Mayor Rudy Giuliani and Methadone



Eventually backed down
But gave the HHC methadone programs a
mandate to get their patients employed
Funneled additional funds to these programs for
Vocational Training
Vocational Training
http://www.alaskacoinexchange.com/Stamps%2034/04c%20Apprenticeship.jpg
32
Vocational Training at the HHC

HHC developed high quality Vocational Centers
in each of the methadone clinics

Patients would not engage with the services that
were being offered
Vocational Training at the HHC


To increase participation,
The HHC Leadership began considering using a
reward program
 Patients would receive gift certificates and
other desirable items if they met goals like:
 Getting a GED
 Finishing a phase of Vocational Training
New York City HHC
Meets NIDA CTN


At the New York Blending Conference
There was a panel on the MIEDAR protocol
Maxine Stitzer, PhD
 Joe Krasnansky, CSW, (LESC)
 Scott Kellogg, PhD
 Marion Schwartz, CSW


Each spoke about different aspects of the
MIEDAR protocol
New York City HHC
Meets NIDA CTN



Marylee Burns, MEd, MA, CRC from the HHC
was in the audience
Recognized both the importance and relevance
of what we were doing
An alliance was formed to bring CM to the
HHC addiction treatment programs
The HHC Addiction Treatment
Leadership Team






Joyce Wale, CSW
Senior Assistant Vice President, New York City Health
and Hospitals Corporation, Office of Behavioral Health
Peter Coleman, MS, CASAC
Director, Office of Behavioral Health
Marylee Burns, MEd, MA, CRC
Assistant Director, Office of Behavioral Health
Forming the Alliance





Met with this HHC leadership team to learn what they
were trying to do
Worked closely with Marylee Burns to refine the
Vocational Incentives that they were beginning to
implement
We eventually visited six clinics or hospitals and
presented the CM model
Each site then developed its own plan for
implementing CM with its patients
They primarily reinforced group attendance
Reward vs Reinforcement

This issue was at the heart of the HHC project
 Probably a central issue in all CM
dissemination efforts
Reward vs Reinforcement
When you speak to staff or leadership about
the use of reinforcements
 They almost universally talk about reinforcing
patients for things like:
 Holding a job for six months
 Being drug-free for 3 months
 Completing a GED or vocational training
program

Reward Programs


This is what I call a Reward Program
Acknowledging patients for achieving a goal or
accomplishing something noteworthy
 Most likely give rewards to the best and most
motivated patients
 While often not changing the behavior of
those patients who are struggling the most
with drug use and treatment compliance
Reinforcement Programs

Reinforcement Program
 Breaks down each of the goals into very small
steps
 Reinforces each of the steps along the way
 Makes it easy to earn a reinforcement
 Distributes reinforcements with fairly high
frequency
Reinforcement Programs




Move from “You have done a good job” to
“You have taken a step in the right direction”
This was the most important change in their
program that we made
It was the difference that made the HHC Project
successful
CTN Results
Using Low-Magnitude
Reinforcements…
METHADONE: PERCENT STIMULANT NEGATIVE URINES
Percent of Submitted Urines Testing Negative
100
Incentive
Control
80
60
o
o
o o o o
*
*
*
*
40
o
o o o o o
o
*
*
*
*
*
*
o
o
o
*
*
*
*
*
o
o
o
*
o
*
*
o o
o
*
*
*
*
*
o*
20
OR = 1.98 CI = 1.45 - 2.65
0
1
3
5
7
9
11
13
Study Visit
15
17
19
21
23
47
PSYCHOSOCIAL STUDY RETENTION
100
100 o
Percent Submitting At Least One Sample
Incentive
Percent Retained
80
60
40
20
OR = 1.6; CI = 1.2 - 2.0
80
60
Control
o
o o o
o
o
o o
o
o
o o
o o
o
o
o
o o
o
o o
40
20
0
0
2
4
6
8
10
12
Study Week
2
4
6
8
10
12
48
CTN Methamphetamine Sub-Study
(Matrix Clinics; n = 113)
CM
TAU
Number of
stimulant-negative
samples
m = 13.9
(SEM = 1.2)
m = 9.9
(SEM = 1.0)
Length of abstinence
m = 9.3
(SEM = 1.2)
m = 5.6
(SEM = 0.9)
Abstinent throughout
entire trial
18%
6%
Roll et al., 2006 in Roll & Newton, 2008
Insights from the
HHC Experience
Leadership is Crucial
Leadership

The successful introduction of contingency
management usually comes from two forces
 The top leadership has made the decision to
implement it
 Idea champions emerge from among the staff
members
52
Leadership

No site successfully adopted CM without strong,
clear, and persevering endorsement and support
from the head of the organization
53
Resistance
Resistance

Counselors are initially resistant or indifferent to
the introduction of CM
Resistance


“I wasn’t a big fan.
I thought that people should go to treatment
because they wanted to be well.” (Counselor)
Patients are
Enthusiastic
Patient Experiences



“Clients were saying…
In Russia, we were forced into treatment –
Now (crying), my God, I’m getting treatment
and $25.00!”
58
Patient Experiences



“Clients are proud and are having fun.
Early in treatment, when their name is called
out, they are feeling good that they are being
acknowledged.
For once in their life, they are being rewarded
for something.”
59
The Reinforcements Get Them
to Go to Group
The Bonding Gets Them to
Stay
Patient Experiences



“The 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 self-esteem and ego.” (Director)
61
Family Healing
Family Healing


Patients used their 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
63
Socializing
and Generosity
Socializing and Generosity



Patients began to socialize with each other
They would use their coupons and go to movies
together in groups
There were also reports that they were taking
care of each other and giving each other gifts
65
Internalization
Internalization


As one counselor put it,
They went from “You are forcing me” to “I
choose”
67
Counselor Acceptance
and Morale
Counselor Acceptance


Once they overcame their resistance,
Counselors reported that they loved the
intervention
 That it was energizing and exciting
69
Counselor Experiences

“It gives me a great deal of pleasure to know
I’m part of a state-of-the-art methadone
treatment program.” (Counselor)
70
Understanding the
Reinforcement Process
Understanding Reinforcement



“We 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.”
72
Patient Gratitude
Patient Gratitude



When patients publicly, and sometimes tearfully,
acknowledge the counselor’s help in public, the
staff felt a sense of gratitude
“In the last two award ceremonies, clients said,
‘I want to thank the staff….’
That sounded real good – we feel appreciated.”
74
Inaugurating Phase II
at the HHC
Epilogue



Would eventually spread to 22 Units –
 6 methadone
 8 medication-free
 6 detoxification units
Thousands of patients became the recipients and
beneficiaries of positive reinforcements
The largest clinical adoption of this technique in
history
NIDA CTN/
HHC Project Integration
NIDA Contingency Management Meeting,
Burlington, VT, October 7, 2004
http://www.moodyscollectibles.com/pixfiles/15024.jpg
Northeast ATTC – NIDA CTN – New York City HHC –
New York Veterans Administration Hospital –
NYSPA Division on Addictions
Co-Sponsored CM Training
October 18, 2005
Promoting Awareness of
Motivational Incentives (PAMI)
The work of the NIDA-CSAT Blending Team
Integrated the experiences of the NIDA CTN
and the HHC Project
Conclusion



One model of dissemination
A mixture of science, clinical practice, and
institutional realities
An example of principle-based dissemination
Acknowledgments




Maxine Stitzer, PhD
Marylee Burns, MEd, MA, CRC
John Rotrosen, MD
Mary Jeanne Kreek, MD
Acknowledgements







Marion Schwartz, CSW
Agatha Kulaga, MSW
Caroline Woo
Joe Krasnansky, CSW
Lolita Silva-Vaszquez, CSW
Joyce B. Wale, CSW
Peter Coleman, MA, CASAC
87
Acknowledgements





Lonetta Albright
Amy Shanahan, MS, CASAC
Nancy Petry, PhD
The leadership, staff, and patients of the New
York City HHC Drug Treatment Programs
NIH-NIDA Grants P60-DA05130,
DA13046-04
88