Contingency Management Example 1 of 4: Prize Tickets to Increase Group Attendance

Disclaimer: nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care.

At a previous workplace, in the early 2000’s, we contracted a person who was a national leading expert in contingency management (CM) for substance use disorders (SUDs). We contracted with them to write a practice guideline on CM for us, and to consult with us on the use of the guideline in our residential and outpatient SUD services. As a result of this consultation we implemented a number of CM strategies across our various programs.

One change consisted of adding a then-cutting edge CM method to our outpatient methadone maintenance program. This method was a prize ticket system used just before the start of group to boost attendance. This was the now-classic “fish bowl” method wherein each patient would pull a ticket from the bowl when arriving for group. The tickets would say “small”, “medium”, “large”, “jumbo” or “try again”. We had a prize cabinet in the group room, and when a prize ticket was pulled, the patient would go ahead and take one item from the shelf in the cabinet that was labeled with that “size” of prize.

We were told this would target the main weakness found in methadone maintenance programs (the low rate of group attendance). And we were told that improving the behavior of attending group would bring those we served many additional benefits (clinical benefits, personal benefits, etc.) through their attendance.

At the time I thought this was odd.

Why? Well, our group attendance rate was very high. And the clinical staff and patients were not approached and asked for their input on what needed to be improved at the clinic-level before this goal was identified and the plan was developed. I also thought it was odd because if we used this plan, the people that no-showed would not be there to receive the reinforcement from the fish bowl prize system.

Regardless, we proceeded with implementation.

Implementation was interesting in one particular way. Over time the counseling staff noticed that whenever someone drew the rare “Jumbo” prize ticket, whoever drew that ticket always put the ticket back in the bowl and declined the reward. Eventually this went on long enough that we realized it was not something related to just one or two particular patients, and everyone was doing this if they pulled the “Jumbo” ticket.

Stumped, we set up a focus group and asked the patients. They laughed and said it was not safe to walk down the sidewalk with a big-screen TV. That’s right: the jumbo prize we were told to use was not a “reinforcer” for our patients.

The reader might wonder what the most popular prizes were. The most popular prizes were actually the ones you got if you pulled a “small” ticket: socks, stocking hats, and so forth. We also eventually learned to use personal items like that rather than things like gasoline vouchers or even bus tickets – as those brought about other particular problems.

Based on this practical experience, do we deduce that the CM strategy of “paying people cash money to use less” would be a great way to implement CM in SUD services?

Lessons learned by our administration from this example of implementing CM included:

The person served decides what is rewarding. The clinician or researcher might think they know what the person will like, but the person served ultimately decides.
The person, their clinical care, recovery support, and CM activities must be understood in context of the person’s life and life situation.

The next post in this series will describe an innovative outpatient group we developed to help reduce the wait and waiting list for residential services.

In case you missed it, here is the series introduction.