Escalating schedules usually include a reset feature. Following a positive or refused sample or unexcused absence, the amount earned for the next negative sample is reduced to the initial amount and begins escalating anew with consecutive negative samples. Some schedules allow for a rapid reset in which after a specified period of time or consecutive performance, the value jumps to the value achieved when the relapse occurred [66].
Despite its consistent inclusion in CM protocols from randomized clinical trials, our data [61] suggest that more than half of providers using incentives in treatment as part of a clinical effort do not use escalating reinforcers. Escalating schedules require more careful tracking of client progress, possibly contributing to lower uptake of this design feature in clinical practice. Development of simple tracking forms can minimize this challenge.
Another drawback of escalation pertaining to prize-based CM is that escalating schedules can affect the duration of CM sessions when clients are drawing a large number of slips each session and escalation can increase costs of the overall program. Capping the number of draws will help mitigate both issues. For example, once a client reaches 10 draws for group attendance, they continue earning 10 draws for each consecutive session attended with no further escalation.
Putting It All Together
CM sessions can be conducted as stand-alone sessions or incorporated into group or individual therapy sessions. Many clinicians will find the latter approach sets a positive tone for the therapy session given CM's focus on what the client is doing well. Starting the treatment session with the CM component often naturally leads into a discussion of relevant therapeutic issues, such as effective coping, slips, or triggers. The CM session length can be variable, but it is typically under 10 minutes. Thus, the CM component need not dominate the clinical session or content. CM sessions for abstinence are scheduled according to a set schedule (eg, Mondays and Thursdays) and often coincide with other treatment aspects (eg, before or after group therapy on Mondays and Thursdays). CM sessions for attendance also generally follow a set schedule (eg, client expected to attend Monday and Wednesday group therapy sessions). The duration of the CM protocol can also vary, with most clinical trials ranging from 12 to 24 weeks. Very short durations are unlikely to produce lasting behavior change, particularly with complex behaviors such as abstinence. Petry [44] recommends no less than 8 weeks duration and a maximum duration of 24 weeks.
As discussed, CM offers many opportunities for tailoring to optimize its fit within the existing structure of clinics. However, this flexibility must be viewed together with an understanding of the principles that impact CM's efficacy. Specific recommendations for CM protocol development will depend on the behavior targeted, the delivery methods, and format (eg, individual versus group settings). For these reasons, consultation with a CM expert is ideal. However, some general guidelines for developing a CM program that incorporate the principles discussed above include an 8- to 12-week program that (1) provides sufficient magnitude to compete with the behavior you are attempting to change, (2) offers frequent opportunities for reinforcement (eg, 2-3 times/wk for opioids or stimulant abstinence, 1-2 times/week for attendance targets; not less than weekly for most behaviors), (3) delivers the reinforcement immediately or very close in time with the behavior (eg, reinforce attendance at the beginning of the group, use onsite urine testing and reinforce immediately after testing), and (4) incorporates escalating and reset features into the schedule.
Clinician Training and Supervision
Training in CM is an important part of the implementation process. Studies [62,84–87] have identified a number of perceived barriers to and negative beliefs about CM, including philosophical and logistical concerns. Tangible incentives, the core of most CM protocols, are generally viewed less favorably than social or nonspecified incentives [84,86,87]. Philosophical concerns relate to CM’s inability to address the underlying causes of addiction, that it does not address multiple behaviors, and that it may undermine internal motivation for sobriety [62,84]. An additional objection relates to paying someone to do what they should do on their own [86]. Logistical and practical concerns often represent implementation barriers such as costs and access to training and supervision, but they also reflect concern for what happens when contingencies are withdrawn, that clients may sell or trade prizes for drugs, and worries that CM’s evidence does not generalize to clinic populations [62].
Many of these beliefs reflect a limited understanding of CM, and addressing these misperceptions is a first step toward reducing resistance to implementation efforts. For example, a substantial body of literature points to CM’s wide generalizability across a range of characteristics, clients that sell or trade prizes for drugs are likely to disrupt their chain of negative samples or attendance, and most studies do not find negative impacts of CM on intrinsic motivation [88–90]. Fortunately, CM training appears to be an effective way to address negative beliefs. In the VA implementation effort [52], training workshops decreased perceived barriers and increased positive impressions of CM [91]. In other training efforts, brief educational materials were effective in changing perceptions of CM’s efficacy [92].
Beyond initial training, supervision of CM delivery is likely to be necessary [93,94]. Clinician skill in delivering CM is related to client outcomes [93,95] and relatively simple adherence measures are available for monitoring [96,97]. However, the best methods for training and supervision of CM have yet to be established. The VA initiative was developed in consultation with CM experts and employed ongoing phone consultation following initial training workshops [52,91]. This approach represented significant investment by the VA toward staff training and CM protocol development that may not be achievable for individual clinics. As attention to CM’s dissemination and implementation has grown, some free resources have been developed. Promoting Awareness of Motivational Incentives (PAMI; www.bettertxoutcomes.org/bettertxoutcomes/PAMI.html) is a collaborative initiative sponsored by the National Institute of Drug Abuse and the Substance Abuse and Mental Health Services Administration. It offers free resources and training materials.
Conclusion
Overall, CM is a highly efficacious treatment for SUDs that generalizes to most clients. Despite a robust evidence base, CM’s implementation in clinical settings lags behind other empirically supported treatments [92]. At least in part, CM’s costs, which include not only staff training and adherence monitoring (as with other treatments), but also costs of the incentives themselves, may contribute to slow uptake in clinical settings. Clinics often do not have the resources available for CM within their operating budgets. However, a growing number of projects [19,52,53,55–57,70,71] illustrate CM implementation within routine clinical care, and increased revenue from improved attendance to treatment groups may be one mechanism through which to fund a CM program [54,56,57]. These projects are valuable not only for demonstrating that CM can be efficacious outside the research setting, but also for highlighting how implementation barriers can be overcome. Continued efforts of this nature are likely to be particularly valuable for clinicians and administrators considering adopting CM within clinical settings.
