Dr Carol-Ann Getty talks about her recent publication on the attitudes of people who use drugs towards contingency management. Dr Getty was an SSA funded PhD student and now part funded by the SSA under their transitional grant and part funded by the addictions department at King’s College London.
SSA: Your article was recently published in Drug and Alcohol Review. You surveyed 181 addiction treatment service users about their attitudes towards contingency management. What is contingency management?
Dr Getty: “Contingency management is a behavioural intervention that is heavily rooted in the science of behaviourism and the principles of operant conditioning. I have written about these before for the SSA website.”
Why do some people have objections to contingency management?
“There are a number of objections towards contingency management including ethical, moral objections. So, things like “it’s not appropriate to reinforce positive behaviour change among this patient group for doing something that they should be doing in the first place”. Other objections include “you shouldn’t pay these individuals for engaging on one target behaviour when they haven’t achieved all their treatment goals”.
“Some objections relate to ‘negative side effects’ of contingency management. One of the main concerns is that contingency management might create jealousy among patients if their peers are getting reinforced for engaging in a behaviour that their keyworker expects them to do anyway.”
“Other objections relate to how resource intensive it is to deliver contingency management, so whether it’s practical and feasible to deliver within treatment services. We know that the treatment services are already stretched and underfunded. But the awareness and experience of delivering contingency management is lacking.”
“People within treatment services may not necessarily know about the evidence base behind contingency management, so they might not advocate for it. Some of those concerns around resources are valid concerns and are concerns that we should acknowledge, address and overcome.”
We use the principles in our everyday life. Who doesn’t like to be rewarded or incentivised for achieving their goals and demonstrating positive behaviour?
“Some previous research into clinician and practitioner attitudes towards contingency management have been within existing interventions, and it’s safe to assume that somebody who agrees to take part in a research trial using contingency management probably demonstrates some level of acceptability towards it otherwise they wouldn’t have agreed to take part.”
“So, that’s where my research study differs, it was among people who were not in receipt of contingency management, so it offers that unique perspective that may be unbiased.”
You looked at the perspectives of service users. What did you find?
“What I found was largely positive, so 81% of those who I surveyed were in favour of contingency management. On the whole, people agreed with the positive, rather than the negative statements. What’s interesting is actually that a lot of the concerns from the literature voiced by clinicians and staff were not shared among the patient population that I surveyed.”
“Around 11% said they would see contingency management as a bribe and that they would find that offensive, so you still have to be a bit cautious because 1 in 10 people might be upset. But within that there was a lot of ambiguity about some of the statements which was particularly important.”
“So yes, we do need to acknowledge those objections and try to understand how we can overcome these barriers that we’re finding, because a lot of the previous work that has been done shows a correlation between endorsement of negative beliefs towards contingency management and the lack of awareness and experience of contingency management. And that was among clinicians.”
“In my survey, 33% of participants were aware of contingency management, so not a big number of people even knew what contingency management was. So, it may be that some of those negative beliefs were linked to a lack of understanding of contingency management.”
To me it’s unethical to withhold an effective treatment because you object to the inner motivation that the patient might have.
Do some people perceive that contingency management might diminish a person’s self-motivation because it provides an external motivator?
“One of the objections towards contingency management is that people might lose sight of their treatment and their intrinsic motivation because they’re receiving a reinforcer. That people would only show up for appointments, achieve abstinence, etc. because of the reinforcer. My response to that would be: isn’t that enough?”
“In some respects, even if people don’t have it within themselves that motivation to change, that encouragement to get them in the door of the treatment service, to attend some of their groups to get the vaccinations to get tested for BBVs.”
“One of the other things to mention about contingency management is that, given these objections and negative beliefs, we use the principles in our everyday life. Who doesn’t like to be rewarded or incentivised for achieving their goals and demonstrating positive behaviour? It’s used all the time in other walks of life, but it never gets the objections that it does here because of the patient group that we’re looking at.”
“To me it’s unethical to withhold an effective treatment because you object to the inner motivation that the patient might have.”
Your particular interest is in technology enhanced versions of contingency management using mobile phones. You found that a lot of people in your sample had mobile phones and were willing to use them, but not all were comfortable with using geo-tracking. Why was this?
“Some of the concerns about delivering contingency management remotely are that, due to digital poverty, not everybody will have access to mobile phones. One of the reasons why we are considering remote contingency management, and why it’s done so much in the states, is to overcome those barriers for people who do not attend treatment services. So, it’s expanding the reach of treatment.”
“So, one of the things that I found in my survey was that around 96% of people owned a mobile and around 85% of those were smartphones. One of the problems is that many people change their numbers often and that makes it hard to keep track of them. So, 27% reported that they had changed their number in the past year. Not a low number, but not huge either that we need to be really concerned about that.”
“With geolocation, only 31% said that they would be comfortable with using that. I’m not surprised, I think I would also be in that 31%. I’m not sure how comfortable I would feel about my doctor tracking my moves or whatnot. I just find that a little bit odd. I asked this question because this feature has been used in previous studies, so thinking about ecological momentary assessments there are some really nice research studies that track an individual’s location and send self-help resources whenever that person is in a difficult geographical situation.”
“So, somebody who is in treatment for alcohol for example, if they are near an area that they have reported to be high risk, so near an off-license or a pub that they frequently attended, they can get automated self-help messages through to their mobile telephone that might help them deal with those cravings. So, that’s why I thought it was important to ask that question, but for contingency management it’s not really something that we use.”
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