Contingency Management Example 2 of 4: “Start Now” in Outpatient and Reduce the Wait for Residential

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

In that same organization during those same years, we had a central screening and intake office for our various residential and outpatient chemical dependency programs.  These were publicly funded programs, and the vast majority of the patients were uninsured.  A large portion of the patients were involved in or referred by various courts (DCFS, county probation, US probation, drug courts, etc.).  The bottom-line problem was that our residential programs were always full, and the central intake office held a waiting list for each residential program.  

Back in those years (the late 90’s and early 2000’s), eager to innovate, we developed the idea of starting an optional outpatient group therapy for those on the waiting list to enter a residential program.  We figured that at least this would eliminate waiting for services and help get recovery started.  We focus-grouped the people on the waiting lists about this idea.  We asked them if getting into an outpatient group and perhaps initiating their recovery was something they would be interested in.  We explained that the screening result that had shown they needed residential was nothing more than a clinical judgment.  And it could be that by entering the pre-treatment recovery-priming outpatient group the person could do well enough that they would no longer be recommended to enter a residential program.  A very large majority of those we asked enthusiastically agreed that this was a very good option to add to our services.

We used the expertise we gained from the contingency management expert consultant we contracted to develop our “Start Now” service.  To make it attractive and easy (promoting engagement) the group was held once each day for 1.5 hours.  We only asked that each person come once a week, and coming more often was optional.  We were encouraged that for this kind of activity that had its own built-in incentive (not needing to enter residential) the best use of contingency management was to add free coffee and donuts. We were told that this would produce the proper welcoming atmosphere and set the occasion for good group work.  In short, this pre-treatment recovery-priming group was a great idea and the eligible participants agreed.  

We prepared for implementation and made sure the group was in the central screening office (safe location, very close to the bus line, etc.) where the patients had already been seen.  We announced the start of this group for weeks prior to implementation.  Once we started the group, the attendance was extremely low – literally only a few people attended. This seemed normal to us at first because it was so new.  Those that attended did enjoy the coffee and donuts.  But over the coming weeks and months the attendance remained no more than a few people at a time, at most.  We were very surprised, given how positive the reaction to the idea had been.  

We finally focus-grouped the low attendance with those attending and those not attending.  The patients told us the reason almost no one was attending was because “It doesn’t count.”  They explained to us that given the residential recommendation and being court-referred they had to comply with the initial recommendation and enter residential treatment regardless, so this group literally didn’t matter.  We were shocked and asked if we got this to “count” with the courts, would they attend?  They said yes, if their progress counted and they didn’t have to do residential, people would attend.  

We spent a few months getting formal agreements from all the various courts that participation and progress in this group would “count”. And that if they progressed enough, that outpatient would suffice.  Once we got those agreements in place the group filled up immediately.  But then there was a waiting list for this “Start Now” group as we named it.  So, we opened a second “Start Now” group.  The second group filled up immediately and it too had its own waiting list.

Over time we saw that some patients did “get recovery” after starting in this group, did well, and did not have to enter residential after all.  And we learned that by doing this we didn’t solve the waiting list problem. We also learned one more thing:  the patients told us that not only did the coffee and donuts not matter to them, but that the coffee and donuts sent them the wrong message.  

Based on this practical experience, do we deduce that paying people with severe, complex and chronic SUDs cash money to use less would be a great way to implement CM in SUD services?  

Lessons learned 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 the innovative addition of a mobile device with live recovery coaching.

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In case you missed it, here is the post on Example # 1.