THE USE OF MOTIVATIONAL INCENTIVES TO HELP ADOLESCENTS RECOVER. Mark Sanders, LCSW, CADC

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1 THE USE OF MOTIVATIONAL INCENTIVES TO HELP ADOLESCENTS RECOVER By Mark Sanders, LCSW, CADC In response to the crack-cocaine epidemic of the 1980s, visionary researchers successfully utilized operant conditioning principles in the form of redeemable vouchers for clean urine drops to help cocaine users achieve abstinence (Higgins, Silverman, and Heil, 2008). This evidence-based approach is called Contingency Management. It also goes by the name Motivational Incentives, which involves offering reward to clients for achieving their goals. Research reveals that low-cost incentives have proven to be effective in reducing cocaine, heroin, alcohol, tobacco, and marijuana use. They have been successful in reducing substance use with a range of client populations, including pregnant women, the homeless, clients with dual disorders, methadone maintenance patients, poly substance abusers, and adolescents (Higgins et al, 2008). Adolescent Resistance and the Use of Incentives Adolescents with substance use disorders face many challenges that lead to resistance and make it difficult to engage them in treatment. These challenges include the fact that: Many adolescents do not find their substance use to be a problem; therefore, the majority lacks the motivation to stop using (Breda and Heflinger, 2004).

This evidence-based approach is called Contingency Management. It also goes by the name Motivational Incentives, which involves offering reward to clients for achieving their goals.

2 2 An increasing percentage of adolescents are mandated to addictions treatment, which produces a resistance of its own (Evans, 2005). Many adolescents who stop using drugs lack motivation for long-term abstinence (Balch et al, 2004). The majority of adolescents would rather stop using drugs on their own than go to treatment (Leatherdale, Cameron, Brown, Jolin, and Kroeker, 2006). In short, adolescents generally have little motivation to stop using drugs and participate in treatment on their own. Studies reveal that the use of motivational incentives has been found to be effective with adolescents with substance use disorders (Corby, Roll, Ledgerwood, and Schuster, 2006; Hanson, Allen, Jenson, and Hutsukami, 2003). These incentives help adolescents in myriad ways, including: Decreased resistance to treatment. Even if they do not believe they have a substance use disorder, they will often actively participate in treatment to receive the incentives (Petry et al, 2000). Once the decision is reached to participate in treatment, adolescents receiving incentives, compared to control groups, achieve greater abstinence, school attendance, improved relationships with their parents, and less depression (Higgins, Silverman, and Heil, 2008). The use of incentives can be particularly helpful when parents are involved in determining and distributing the rewards (Dishion, 2003;

The majority of adolescents would rather stop using drugs on their own than go to treatment (Leatherdale, Cameron, Brown, Jolin, and Kroeker, 2006).

3 3 Higgins et al, 2008). Examples of parental reinforcers for adolescents include: o allowance; o special gifts; o increased responsibilities; o later curfew; o telephone privileges; and o computer and other technology use. Behaviors that incentives have proven to help reinforce with adolescents include: abstinence; individual therapy attendance; group therapy attendance; school attendance; prosocial behavior; improvement in grades; and discontinuation of nicotine use (Sussman, 2002; Higgins, 2008). 7 Principles of Motivational Incentives There are seven principles involved in the successful utilization of motivational incentives. They include: 1. Identification of the target behavior. The target behavior is something that is problematic for the client population and is in need of changing. With adolescents this could involve abstinence rates, individual therapy attendance, group therapy attendance, school attendance, etc.

Behaviors that incentives have proven to help reinforce with adolescents include: abstinence; individual therapy attendance; group therapy attendance; school attendance; prosocial behavior;

4 4 2. Choice of target population. It might be great to provide reinforcements for all client populations, and of course, this can be costly. It is therefore helpful to provide incentives for those populations who are particularly vulnerable. This could include pregnant women, methamphetamine users, clients with dual disorders, polysubstance users, chronic relapsers, new clients, or adolescents who do not believe they have a problem with drug use. 3. Choice of reinforcers. Reinforcers are most effective if they are desired by the target population. What may serve as a reinforcer for a homeless adult will differ for an adolescent. It can be helpful to involve the target population in choosing effective incentives. For adolescents, reinforcers can include privileges, the use of technology, or free participation in desired activities. 4. Incentive magnitude. Higher level incentives produce greater results (Higgins et al, 2008). Intermittent reinforcers work better in the long run and can be cost-effective (Petry, 2005). An example involves the use of the fishbowl technique, in which clients are allowed to draw a raffle ticket and possibly win a small, medium, large, or grand prize for achieving the target behavior. There is a fifty percent chance that the client will not win a prize on a given day, because one-half of the raffle tickets read, Keep up the good work. In group settings, even drawing this ticket can lead to a round of applause from other clients present, which can in itself be reinforcing.

This could include pregnant women, methamphetamine users, clients with dual disorders, polysubstance users, chronic relapsers, new clients, or adolescents who do not believe they have a problem with

5 5 5. Frequency of attendance. It is often helpful to offer incentives more frequently when client motivation is lowest or when abstinence is more difficult to achieve. These periods can include phases of acute withdrawal, the first forty-eight hours after being released from treatment, the initial period when adolescents return from treatment back to school, or within the first ninety days after discontinuing drug use. This can be followed by intermittent reinforcement. 6. Timing of the incentive. The sooner receipt of the incentive occurs after achievement of the target behavior, the more reinforcing the incentive (Kellogg, 2005). 7. Duration of the incentive. It is helpful to continue providing external incentives until naturally occurring reinforcers can kick in (Kellogg, 2005). Examples of naturally occurring incentives include: an internal desire for abstinence; healthy family support; altruism; a ninety-day period of abstinence; and gratitude. Programs utilizing the fishbowl technique often have one grand prize, which is statistically difficult to win. With 250 raffle tickets in the fishbowl, a client has a one-in-250 percent chance of winning the grand prize. I was recently told that in one program utilizing the fishbowl technique, a client actually won the grand prize, a $250 television. To the amazement of those watching, he donated

within the first ninety days after discontinuing drug use. This can be followed by intermittent reinforcement. 6. Timing of the incentive.

6 6 the television back to the program that had helped him. He stated that he was grateful for his recovery. This suggests that with time internal motivators such as gratitude can successfully replace external motivators such as incentives. Relapse rates remain extremely high. Over fifty percent of chemically dependent clients relapse, and eighty percent of those relapses occur within the first ninety days after these clients leave treatment (White, Kurtz, and Sanders, 2005). As a field, we need to be on the lookout for approaches that help clients recover. The use of motivational incentives is one such approach. RESOURCES Balch, G., Tworek, C., Barker, D., Sasso, B., Mermelstein, R., Giovino, G. (2004). Opportunities for youth smoking cessation; findings from a national group study. Nicotine and Tobacco Research, 6(1), pp Breda, C. and Heflinger, C. (2004). Predicting incentives to change among adolescents with substance use disorders. American Journal of Drug and Alcohol Abuse, 30(2), Corby, E., Roll, L., Ledgerwood, D., and Schuster, C. (2000). Contingency management: interventions for treating the substance abuse of adolescents. Experimental and Clinical Psychopharmacology, 8(3), Dishion et al (2003). Family Management Curriculum, V2.0: A Leader s Guide. Eugene, OR: Child and Family Center Publications. Evans et al (2005). Treating and Preventing Adolescent Mental Health Disorders. New York, NY: Oxford University Press.

Over fifty percent of chemically dependent clients relapse, and eighty percent of those relapses occur within the first ninety days after these clients leave treatment (White, Kurtz, and Sanders,

7 7 Higgins, S., Silverman, Heil, S. (2008). Contingency Management in Substance Abuse Treatment, New York: Guilford Press. Hanson, K., Allen, S., Jensen, S., and Hatsukami, D. (2003) Treatment of adolescent smokers with the nicotine patch. Nicotine and Tobacco Research, 5(4), Leatherdale, S., Cameron, R., Brown, K., Jolin, M., and Kroeker, C. (2006). The influence of friends, family, and older peers on smoking among elementary school students: low-risk students in high-risk schools. Preventive Medicine, 6, Kellogg, S. and Kreek, M. (2005). Gradualism, identity, reinforcements, and change, International Journal of Drug Policy, 16, Kellogg, S., Burns, M., Coleman, P., Stitzer, M., Wale, J., Kreek, M, (2005). Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, Petry, N. (2000) A comprehensive guide to the application of contingency management procedures in clinical settings. Drug and Alcohol Dependence, 58, Petry, N., Peirce, J., Stitzer, M., Blaine, J., Roll, J., Cohen, A. et al (2005b). Effect of prize-based incentives on outcomes in stimulant abusers: an outpatient psychosocial treatment program: A national drug abuse treatment clinical trials network study. Archives of General Psychiatry, 62,

The influence of friends, family, and older peers on smoking among elementary school students: low-risk students in high-risk schools. Preventive Medicine, 6, 218-222. Kellogg, S. and Kreek, M.

8 8 Sussman, S. (2002). Effects of sixty-six adolescent tobacco cessation trials and seventeen prospective studies of self-initiated quitting. Tobaccoinduced Diseases, 1(1), White, W., Kurtz, E., and Sanders, M. (2006) Recovery Management. Great Lakes ATTC Monograph.

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