contingency management

[Jim]

dear members

I would be really interested to start a debate on this.  This is the system of giving monetary rewards to people who make improvements in treatment.  Probably in the form of £5 or £10 vouchers.  It has been recommended by NICE in their rarft psychosocial guidance.  It has a positive reseach evidence base but primarily from the US- none from the UK. 

We at SMMGP (Substance Misuse Management in General Practice) have done a member consultation on this.  However none of the respondants so far have been service users (I'm not sure how many, if any, of our members are service users - you're very welcome to join it's easy and free just fill in the form on-line at www.smmgp.org.uk ) so it would be really useful to get a feel about what people using services think about it.

Our preliminary results show the main concerns are 1. how it  is going to be monitored and rewards given out and the possibilities of fraud and a breakdown in the terapeutic relationship 2.  That it will create a major public/media backlash which could seriously damnage the treatment field  3.  How it will be funded and what other services may suffer as a result.

However many people were broadly in favour saying it would reinforce the benefits of treatment, would be a tangible reward and might be a way of better engaging with stimulant users (the recommendaton was for all treatment groups, however),

what do you think?

[simon]

Jim,
One of my concerns is that we don't want to discourage honest self-reporting and to encourage people to fetch other peoples Urine samples. Oral swabs are of course much  more expensive. I'm still divided on my views over contingency management and would have preferred a pilot project.
I suggested locally free gym passes or other things that could promote healthy lifestyle changes.

[Maddy]

I think that 'rewarding'people for 'improving' in treatment is an absolute minefield. I agree with simon that gym passes are a really great idea, I was working on Nottingham until recently (working in drug services and also being a drug user myself which wasn't a great combination in my ex-managers eyes!) and free passes to the gym were readily available to people using the local statutory drug service, but again I don't think that they should be linked to attainment in any way. Who should say what an improvement is, who except the user, we are after all individuals, can say who is acheiving, and whatis achieving anyway? Where is the line? Discretion is the key, but would also be the cause of an awful lot of disagreements about who should be given vouchers and who shouldn't. After all, vouchers have a value so are still a financial reward and surely part of treatment should be breaking down and moving away from the financial part of (chaotic/problematic) drug use.

Maybe I'm being naive, but I have always thought that a good treatment worker should have enough in the way of people skills, motivational techniques, understanding, genuine empathy, and the ability to help the us examine our own motivation for seeking treatment in the first place for them to not need to offer tokenistic tesco vouchers if we offer a clean piss test! Although there have been times when I have been stupidly skint and 5 quids worth of shopping would have helped me through (I'm sure we've all been there!) I would still personally have felt belittled and patronised if I had been given vouchers in such circumstances. As the saying goes, I'm doing this for me, no-one else....

I hope I have got the gist of this thread/debate and not got the wrong end of the stick completely.....(it wouldn't be the first time!)

love to all

Maddy x       

[steviemac]

Hi Jim,
Wouldn't  it be better if the funding that would be required for such a scheme be used in improving the services that are already available.

This includes rehab places which are available as i recently got a letter from the rehab i was in asking me to question the mp's at the last local election,WHY they had empty beds due to the fact funding was not available,we have to remember there are people dying out there who in my opinion would rather have a bed than a tesco voucher or a gym pass which would be the last thing i would want if in active using.

So how do we agree who qualifys? Clean time,only methadone patients,clean urines etc etc.

So Jim where do we draw the line,do we only give these 'REWARDS' to people who have engaged treatment positively.On the other hand if someone wants to go to the gym there is already ways of engaging this service----your doctor can actually prescribe exercise at a gym and gyms also offer good concessions to people who may not be working.

You can't bribe someone to get well,they have to want it and im afraid TESCO is the last place i would be going if using , unless they started selling good gear!!!

 Take Care

STEVIE

[Jim]

I'm not saying whether I'm in favour of this or not, but in a couple of months it could be official policy as laid down by NICE.  It will be shopping vouchers or cash rather that gym vouchers.   

[sturitchie]

mmm... this one is amine field from a service users point of view i find tokens and vouchers a bit paternalistic with undertones of dont give em cash thell spend it on drugs which says a lot about poeple expactations of service users in treatment. Any way vouchers will be sold for less than face value if someone is determined to raise cash this way.
 If these were given as a result of client lead goals i might be in favour but if anyone thinks giving service users the odd fiver or tenner will make them comply to anything really doesnt know who they are dealing with.
 our dat has been doing this to improove attendance at events a fiver for learning first aid upto 20 quid for representing service users at a dat meeting paid in cash in white envelopes no less, it has made very little difference to numbers and the events are so far and few appart no one is going to make much.
At a recent series of consultaion events service users were given 10 quid each if they attended but some thought they got 10 quid for attending each of the three when the payment was a one off when this was annoiunced at the second meeting only 2 people got up and left.
Recently someone very active in service users issues from a entrenched 12 step point of view tried to bring in a symptomatic relief programme involving free passes to gyms vitamins and complimentary therapies it was presented as a well researched document of fact that it worked , i found out later that it worked for 10 indivduals who choose it who got clean for 30 days no folow us were done and it was on this exceptionally limated anectodtal evidence that the choice of syptomatic relief with presribed medications was nearly removed from people in this area I am very wary about any idea that reduces service users choice and service user led treatment plans.
Over all i think the incentives will make no difference at best and at worst will damage the reputation of treatment providers who have to stay squeaky clean in order to continue to fight the stigmatization of people who wish to address their chatic drug use.
I dont really have a definative answer but i hope this is food for thought.   

[Jim]

attending a consultation event should eb paid for anyway.  Service users are giveing a service they do not have to give by attending.  They would be paying GPs to turn up.   This however is not contingency manangement.  That is paying people to comply with treatment.  Even the first aid  example is a service they are giving if you think about.  What we are talking about here is 'no heorin in your urine -- ten quid.

[simon]

attending a consultation event should eb paid for anyway.  Service users are giveing a service they do not have to give by attending.  They would be paying GPs to turn up.   This however is not contingency manangement.  That is paying people to comply with treatment.  Even the first aid  example is a service they are giving if you think about.  What we are talking about here is 'no heorin in your urine -- ten quid.

Or no Heroin in someone elses urine - ten quid
I do not want to go down the oral swab route it's just so much more expensive. I also do not want to be spending my time dishing out vouchers. Seeing as the research was American I'm assuming but cannot remember but I bet they were supervised ? I also do not want to do this.

[sturitchie]

I understand the examples i gave were not contingecy management but i still believe they are valid examples of involving payment in treatment.
 I am not for this at all unless like i and others have said the goals they are being rewarded for are client led, but generally the benifits of actively engaging with treatment far out weigh the odd bit of cash here and there. lets be real if you cant stop using to save a marrage or job or to keep your kids i cant see you turning your life around for a tenner.
 I would be infavour of rewards that fit the treatment plans of the client for example if someone wants to tackle weight loss in order to improove their self esteem then vouchers for the gym may be approriate, if someone wishes to improve their employment chances maybe thers a point in clothing vouchers for an interview, but this is allready covered by other agencies and theres a risk of diluting what your trying to acheive.
 Contingency management stikes me as  tautilogical management speak it is after all the job of a manager to plan for contigencies , kind of goes with the job.
I think it a shame that the valid points i made were overlooked whether they were right or wrong a discussion may have been more benifical than poo pooing my understanding of the topic. It a real shame generally i found people more supportive on here.
 One of the complaints i heard a lot from service users was that they didn't understand the language used in a lot of meetings when they try to get involved and i have to agree i found it hard work getting upto speed with all the jargon.
 If this is really just about getting paid for staying clean then i think it is not only a bad idea that wouldnt work for the cleint but the backlash could do some serious damage to treatment providers. I can see the headlines now and would this also apply to people on drug treatment orders.
 Well thats what i think anyway and after all thats what a forum is for open discussion and a frank exchange of ideas.   
 

[Jim]

sorry

I was not trying to poo poo your ideas, I just was trying to keep find out peoples views of contingency management (which is a very misleading term in my opinion-I did not pick it).  I was concerned that I might not have explained it adequately.   I was just trying to clarify and again I completely apologise if this came over wrongly.

[mcdermott]

As with everything in the drugs field -- perhaps everything in the world -- the value of contingency management depends on how and where it's used. The idea that we'd pay everybody or give everybody vouchers, simply for attending a service is just plain silly. (Not that you were suggesting this, Jim, but I have heard the argument made as to why we shouldn't do it.)

However, for time-limited, goal specific things, the efficacy is clearly demonstrated by the research. And we already use something very similar, when trying to have people participate in research studies. The suggestion, in part, is that this is extended to having people participate in specific health campaigns, such as vaccinations, etc.

The other place where I think it has value is when a client has a personal goal that they are struggling to make. This might be becoming abstinent, avoiding using street heroin or crack cocaine or something similar. Again, it would have to be time limited -- say, to ten sessions -- but again, there's very clear evidence from the USA that contingency management works better than everything else available in this situation, so why wouldn't we use it?

Curiously, in this context, there is evidence that smaller rewards actually have a greater impact on motivation than larger financial rewards. Not sure why this should be. Perhaps people might see them as a bribe? Or perhaps if you gave people fifty quid, it would be too much temptation to go off and buy a rock? But I think this may apply outside drug treatment as well.

One reason for the anxiety about this, I suppose, is that many drugs workers have a big personal investment in their powers as 'therapists', and the idea that giving somebody a couple of ten pounds vouchers could have a much greater impact may be a serious threat to their self-esteem? However, we don't appear to have problems attracting people to work in the field (though attracting quality people sometimes seems a challenge), so I wouldn't get too het up about that.

Disclaimer: I sat on the NICE group that produced this report, so I've got a personal emotional investment in seeing it go forward. That said, it was impossible not to be swayed by the overwhelming weight of the evidence.

[simon]

I also commented on the guidelines for the Royal college of Nursing and decided not to comment on this part as it seemed sensible looking at the evidence but it didn't quite fit easily with me.

[sturitchie]

thanks for your comments jim , but i think i was a bit oversensitive  reading what you said in the light of how you explained it there is nothing to take offence at so please accept my appologies too.

[mikey]

Just on the issue of vouchers versus cash-

I have been involved in a fair few of these (cash and vouchers)and the pattern has never changed one iota.......

a cash reward sees people (*)rushing off, clubbing together, making frantic phone calls and generally behaving as they have every right to as individual human beings.

A voucher see people rushing off to Morrisons/ Tescos/ etc etc to try to weigh them in , pull some scam, or stand outside pestering shoppers to buy them for half price....then they go back to continue from the point marked (*).

So what is different? Vouchers and cash produce the same result only one has the added bonus of humiliation, stress, affirmation that you are beneath the ordinary decent citizen. All kinds of stuff thgat is really helpful to the recovery of a drug user eh?? Not really.
So a participants recovery pays the price ultimately for having their input when you give out vouchers instead of cash.

Vouchers serve the control freaks not the experts.
Jim. Would you turn up for work for Tesco vouchers? Ah, but I suppose that's different. Cos you're different.? really?.

[Jim]

but its different to turning up for work.  Participating in research is work, attending training is work.  This is being paid to be treated.  I would attend my GP for my statin prescription for Tescos vouchers as I attend anyway without this.  It might even make me more compliant with taking them and watching my diet to lower my cholesterol if this was what was expected.   This is where this is coming from.  Actually I wouldn't as I hate Tesco and try not to shop there.