“It doesn’t address the underlying cause of addiction.”
“It will undermine the patient’s internal motivation for abstinence.”
“Its effect will last only as long as rewards continue to be given.”
Clinicians affiliated with the Veterans Administration (VA) discounted the significance of these and other common criticisms of contingency management (CM) treatment for substance use and dependence (SUD) after attending 1.5-day training workshops on the intervention. Instead, they gave more weight to statements that reflect CM’s proven benefits, such as, “CM helps clients get sober so that they can work on other aspects of recovery.”
CM is a behavioral modification technique that rewards good behavior to motivate further good behavior. Despite being highly effective at decreasing drug use, it is one of the least used among proven substance abuse treatments. Responses from the clinicians who attended the VA workshops suggest that training can help alleviate this situation. The clinicians’ post-workshop ratings of positive statements about CM predicted their self-assessed readiness to implement the intervention in their home clinics. Their ratings of critical statements about CM correlated negatively with readiness to a degree just short of significance.
Knowledge Breeds Respect
Dr. Carla Rash and Dr. Nancy Petry, both of the University of Connecticut Health Center, conducted the four workshops, each in a different region of the Nation. The VA, which endorsed CM in 2011, sponsored the training as part of a push to make CM available in all of its intensive outpatient substance abuse treatment programs.
The workshops covered the behavioral principles that underlie CM, research supporting its efficacy, and practical implementation. The trainers used videos and live demonstrations, role play, and group discussions to engage the attendees and deliver the workshop content. They provided advice on how to design a successful program, highlighted how to identify ideal patients for CM, walked attendees through an effective reward system, and discussed common implementation challenges.
The 159 workshop participants hailed from 113 VA clinics. Before and after the training, Dr. Rash and colleagues asked them 20 multiple choice questions to evaluate their understanding of basic behavioral principles that underlie CM. The attendees also completed a Contingency Management Beliefs Questionnaire, which asked them to rate 35 statements according to how much weight they gave each one in their decision to adopt or continue using CM.
The clinicians’ scores on the knowledge test improved markedly following the workshop. Such understanding is critical, Dr. Petry says, because practitioners who implement CM without it may fail to achieve success and so deem the intervention ineffective. CM protocols require frequent objective monitoring of clients’ abstinence and a tangible reward handed out each time abstinence is demonstrated. “Every time a client has a negative urine sample, they get a reward—ideally rewards that increase in value over time,” Dr. Petry says. Rewards can range in value from bus tokens and toiletries to gift cards for coffee or kitchen items.
The workshops helped allay reservations that even receptive clinicians had about using CM. The biggest jumps in favorable impressions were related to CM’s focus on the positive in clients’ behaviors, facility to target abstinence, and ability to keep clients engaged in treatment long enough to learn valuable skills.
In addition to their rating of positive statements about CM, the clinicians’ perceptions of potential training barriers predicted their readiness to implement the intervention. For example, stronger concern over perceived unavailability of training opportunities and qualified supervision for CM correlated with lower readiness.
The researchers note that the VA training outcomes may have been influenced by the fact that the participating clinicians had a higher average level of education than the SUD workforce as a whole, and some may have been selected to represent their clinics because they had a prior interest in CM. Dr. Rash also notes that the workshop setting was a top-down implementation effort in which the VA provided the training, support, and funds.
Dr. Petry concludes, “Our data show that perceptions of contingency management are malleable, which is encouraging for its adoption.” She adds that future research needs to evaluate whether CM knowledge or beliefs can predict a clinician’s eventual adoption of the technique. Meanwhile, 80% of the clinics that were invited to send participations to the workshops are now using CM with patients.
Stigma Against a Treatment
“Contingency management has a lot of stigma. The real question in the field has been, ‘Can you get people to change their perceptions of this approach?’ ” says Dr. Lisa Onken, Chief of NIDA’s Behavioral and Integrative Treatment Branch. “This is a really important study because it shows that at least one of the barriers to implementing contingency management can be modified,” she adds. However, she points out, multiple additional barriers—including, for example, cost and time constraints—must also be overcome to successfully implement the intervention.
A lot of research has been done on barriers to implementing good evidence-based interventions for drug addiction, but little on how to reverse or overcome some of these barriers, says Dr. Onken. “The study is an important first step toward determining whether or not changing the perceptions of a treatment program results in its increased implementation.”
This study was supported by NIH grants DA023918, DA09241, DA031897, and DA029062.
Rash, C.J.; DePhilippis, D.; McKay, J.R.; Drapkin, M.; Petry, N.M. Training workshops positively impact beliefs about contingency management in a nationwide dissemination effort. Journal of Substance Abuse Treatment 45(3):306-312, 2013. Abstract