This document discusses the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. It describes how researchers from the NIDA Clinical Trials Network collaborated with the New York City Health and Hospitals Corporation to implement these interventions. Key points: - The HHC adopted contingency management (positive reinforcement for treatment goals) based on scientific evidence of its effectiveness. This grew from collaboration between NIDA researchers and HHC leadership. - Interviews found that contingency management increased patient motivation, facilitated progress, improved staff morale, and developed more positive relationships among patients and staff. - The HHC underwent changes like adding vocational services and changing the focus to recovery and self-sufficiency before introducing contingency

1. Regular article
Something of value: The introduction of contingency management
interventions into the New York City Health and
Hospital Addiction Treatment Service
Scott H. Kellogg, (Ph.D.)a,
*, Marylee Burns, (M.Ed.), (M.A), (CRC)b
,
Peter Coleman, (M.S.), (CASAC)b
, Maxine Stitzer, (Ph.D.)c
,
Joyce B. Wale, (CSW)b
, Mary Jeanne Kreek, (M.D.)a
a
The Rockefeller University, New York, NY, USA
b
Office of Behavioral Health, The New York City Health and Hospitals Corporation, New York, NY, USA
c
Johns Hopkins School of Medicine, Baltimore, MD, USA
Received 15 May 2004; received in revised form 20 September 2004; accepted 28 October 2004
Abstract
This paper explores the impact of the adoption of the contingency management approach by the Chemical Dependency Treatment
Services of the New York City Health and Hospitals Corporation (HHC). The utilization of this approach grew out of an alliance between
NIDA Clinical Trials Network-affiliated clinicians and researchers and a leadership team at the HHC. Interviews and dialogues with
administrators, staff, and patients revealed a shared sense that the use of contingency management had: (1) increased patient motivation
for treatment and recovery; (2) facilitated therapeutic progress and goal attainment; (3) improved the attitude and morale of many staff
members and administrators; and (4) developed a more collegial and affirming relationship not only between patients and staff, but also
among staff members. D 2005 Elsevier Inc. All rights reserved.
Keywords: Contingency management; Positive reinforcement; Addiction treatment; Methadone; Vocational rehabilitation
1. Introduction
The process of institutional change can appear complex
and intimidating. This paper tells the story of the successful
adoption of a new empirically-based treatment, contingency
management (CM), by a diverse array of chemical depen-
dency treatment programs within the largest public hospital
system in the nation. The project involved the collaboration
of scientifically-oriented researchers and clinicians from the
Clinical Trials Network (CTN) of the National Institute on
Drug Abuse (NIDA) and an innovative leadership team
from the New York City Health and Hospitals Corporation
(HHC), a public benefit corporation in which the treatment
programs reside. When the project moved out into the field,
the hard work and creativity of the counselors and other
clinical staff who further refined the contingency manage-
ment programs and implemented them in their clinics and
the enthusiasm of the patients were key ingredients in
making it a success.
2. The Health and Hospitals Corporation
2.1. Background
The New York City Health and Hospitals Corporation
was established as a public benefit corporation in 1970 and
is a large municipal health care provider, with 11 acute-care
0740-5472/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2004.10.007
* Corresponding author. Box 171, The Rockefeller University, 1230
York Avenue, New York, NY 10021-6399, USA. Tel.: +1 212 327 8282;
fax; +1 212 327 7023.
E-mail address: kellogs@rockefeller.edu (S.H. Kellogg).
Journal of Substance Abuse Treatment 28 (2005) 57–65

2. hospitals, six diagnostic and treatment centers, four long-
term care facilities, over 100 community health clinics, a
managed care organization (MetroPlus), and a certified
home health care agency. In addition to primary heath
care, HHC provides a full array of mental health and che-
mical dependency services, operating over 1,200 inpatient
behavioral health beds that generate 20,520 patient dis-
charges per year, and outpatient services that generate over
472,000 visits a year. The array of chemical dependency
treatment programs within HHC facilities includes: eight
methadone treatment programs, 19 outpatient chemical
dependency treatment programs, eight inpatient detoxifica-
tion units, two halfway houses, a residential program run in
partnership with a community-based provider which offers a
medication taper and added support for those patients
wishing to discontinue their methadone treatment, four
hospital intervention and referral services, and an intensive
case management program. At the start of the collaboration,
HHC had been engaged in a process of evaluating their
treatment structures and developing practice guidelines in
order to improve treatment outcomes through increased focus
on recovery, self-sufficiency, and employment.
2.2. An agency in transition
In 1998, HHC was awarded funds by the New York State
Office of Substance Abuse Services (OASAS) to add a
vocational rehabilitation counseling component in five of
its methadone clinics. The award stipulated that the clinics
needed to revise their programs to reflect an integration
of vocational and clinical services and develop a bworker-
friendlyQ culture. The following year, after methadone
treatment in New York City was directed to place a strong
focus on self-sufficiency, additional funds were provided by
the City to further enhance the services offered by HHCTs
methadone treatment and drug-free outpatient programs by
enhancing their vocational services. In 2000, there was a
second award of funds from OASAS, which added still
more vocational resources.
With this infusion of funds, HHCTs methadone clinics
underwent a profound structural and philosophical change,
reflected in a conscious decision to change clinic names
from methadone maintenance to methadone treatment pro-
grams. A workgroup made up of physicians, program ad-
ministrators, and representatives from various disciplines
standardized practice guidelines and revised clinic manuals
for all of the methadone programs. Clinics and staff were
strongly encouraged to embrace rehabilitation, recovery, and
self-sufficiency both philosophically and as primary treat-
ment goals. It was expected that evening and Saturday hours
of operation would be added, caseloads would decrease, and
more intensive counseling services including group treatment
would be offered. Career centers, equipped with computers,
vocational tests, videos, workbooks, video cameras, televi-
sions, and VCRs, were also established in each clinic. Pro-
gram administrators meet regularly and worked closely with
corporate staff to share ideas and address obstacles, and
a statistical reporting system was instituted to collect and
analyze data. Similar changes were also being put into place
in the outpatient chemical dependency programs.
The second wave of efforts to foment institutional change
and facilitate staff bbuy-inQ included an HHC-organized,
day-long workshop for administrative and line staff of the
methadone programs entitled Multidimensional Solutions in
Substance Abuse Treatment: Thinking Outside of the Box.
The training emphasized not only the importance of
respecting the patientTs values, wishes, and culture, but also
the need to be aware that change was a cyclical, individual
process. In addition, clinics were encouraged to adopt the
transtheoretical model of behavioral change as a guiding
principle in developing treatment plan goals and matching
interventions. OASAS assisted by making available a 2-day
training entitled Project Invest that focused on the integra-
tion of vocational rehabilitation into the treatment process.
A third phase of interventions began when HHC de-
veloped, funded, and launched a Patient Recognition and
Motivation Initiative in the fall of 2001. This initiative was
based on research and experience that supported the use of
tokens to encourage and motivate patients to attain treatment
goals. Recognition of patient achievements was felt to be a
valuable mechanism to acknowledge success and the attain-
ment of treatment goals, to further a positive self image, to
provide staff and peer support, and to motivate others by
furnishing peer models they could emulate. HHC initially
developed a recognition plan template that was expected to
serve as a model for the clinics to use in developing their
own, individual plans. Programs interested in participating
in this initiative had to submit a detailed plan for the estab-
lishment and ongoing support of a Motivation and Patient
Recognition Initiative. The primary focus of this initiative
was to be on vocational goals, with substantial emphasis on
employment and employment retention. However, recogniz-
ing that this is but one piece of drug treatment, and that
barriers to recovery and employment are many, Motiva-
tion and Recognition Initiatives were also required to be
developed in such a way to recognize advancement in treat-
ment and attainment of other significant milestones as well.
It was at this point that the HHC leadership came into con-
tact with researchers actively engaged in implementing con-
tingency management protocols.
3. Contingency management
The use of contingency management or positive rein-
forcement approaches in the treatment of addictive disorders
has received increasing levels of attention in recent years
as scientific studies continue to demonstrate its efficacy
with diverse substance-using populations (Higgins, Alessi,
& Dantona, 2002; Petry, 2000; Petry, Martin, Cooney, &
Kranzler, 2000; Petry et al., 2001; Silverman et al., 1996;
Stitzer, Iguchi, Kidorf, & Bigelow, 1993). As a reflection of
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–6558

3. this development, the contingency management approach
was one of the first chosen to be tested by the CTN. Called
Motivational Incentives to Enhance Drug Abuse Recovery,
the protocol was primarily aimed at cocaine and metham-
phetamine use among participants in methadone and
medication-free treatment settings.
One of the goals of NIDA and the CTN is the dis-
semination of effective, research-based interventions into
the broader community-based treatment field. To this end,
NIDA has been involved in the creation of a series of
Blending Conferences—conferences in which treatment
providers and scientifically-oriented researchers and practi-
tioners can meet, dialogue, and, hopefully, form alliances to
help move the treatment field forward. It was at the NIDA
Blending Conference in New York in March of 2002 that
the two groups first made contact—an encounter that ful-
filled one of the ambitions of the conference organizers.
The CTN faculty and HHC leadership met and a partner-
ship emerged. The partners then visited the front-line clinics
that were interested in being a part of this motivational
initiative and discussed their plans with them.
4. From rewards to reinforcements
Although the programsT plans reflected an understanding
of reinforcement principles, the majority of the interventions
occurred too long after the targeted behaviors. The plans
that were being developed were designed to brewardQ
patients for achieving major accomplishments—going to
groups on a regular basis, finishing a vocational training
program, keeping a job for 30, 60 and 90 days, and being
drug- and alcohol-free for 2 months. In a sense, it was a
program to reward bvirtue,Q as the incentive/token comes
after the completion of significant progress toward recovery.
There also seemed to be a risk that this kind of intervention
would only have an impact on the bbestQ patients, i.e., those
who were already very motivated and high functioning.
In turn, the CTN group felt that transforming the
intervention into a breinforcementQ system would increase
the likelihood of reaching and motivating patients who were
currently the least responsive to treatment and most in need
of help (Petry & Bohn, 2003). Contingency management
programs can be designed to reinforce each of the small
steps and each of the components that are involved in
reaching the goal, not just the attainment of the goal. They
can be more gradualistic and the focus is more on using
motivational approaches to initiate and maintain behavior
change. Again, especially early in the process, it can be
helpful if the reinforcements are easy to earn and distributed
frequently (Kazdin, 1994). This way, not only the most
motivated patients, but also those who are more troubled
and/or more severely addicted have the opportunity to
benefit (see also Petry et al., 2001).
From a strictly behavior-analytic perspective (Kazdin,
1994; Wolpe, 1982), this distinction between breinforcementQ
and brewardQ is incorrect. They are both forms of reinforce-
ment. The difference is that the criteria in the brewardQ
condition is much greater than that in the breinforcementQ
condition. Nonetheless, in our dialogues with the staff and
the administrators at the clinics, the use of the social con-
structs of breinforcementQ and brewardQ appeared to be quite
meaningful and this reconceptualization of the process led
to the development of more effective plans.
5. Engaging the clinics
In order to lay the foundation for an effective interven-
tion, presentations were made to the clinic leadership and to
the staff at each of the five clinics by Dr. Scott Kellogg,
covering the theory, practice, and research findings on
contingency management interventions in substance-abuse
settings (Mid-Atlantic Node, 2000), as well as patient ex-
periences from other CM projects within the CTN.
In this process, several core principles concerning the
use of reinforcements were emphasized in our presentations
to the staff and the leadership (see also Kirby, Amass, &
McLellan, 1999). These were:
1. Reinforcements should be given very frequently.
2. It should be very easy to earn reinforcements at the start.
The bbarQ should be kept low. As an example, there was a
discussion about the fact that when the trainers at Sea
World begin to teach the whales to jump over the hoops,
they start with the hoop being under the water, and the
whales are given reinforcements for simply swimming
over it (Coonradt, 1996).
3. To be as effective as possible, the reinforcements needed to
include material goods and services, and these need to be
of use and value to the patients. Social reinforcement alone
was not likely to be as effective, especially for patients
who were disconnected or socially phobic.
4. The reinforcements would be most effective if their
distribution was directly connected to specific and
observable behaviors and if they received them imme-
diately after they exhibited the behavior (i.e., attending
the group). The greater the delay in receiving the
reinforcement, the weaker its effect was likely to be
(Kazdin, 1994).
5. Counselors and staff were encouraged to focus on the
good things that the patients did, not their failings. In this
vein, any steps in the right direction were a cause for
celebration, and in the face of setbacks, patients should
be encouraged, not criticized.
A few other clinical points were emphasized as well. The
criteria for earning a reinforcement should be clear to both
the patients and the staff members. All eligible participants
who met the criteria were entitled to receive the reinforce-
ment regardless of whether or not he or she were meeting
other treatment objectives. In addition, the staff members
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–65 59

4. who were not enthusiastic about this intervention or even
opposed to it were offered a chance to exclude themselves
from the distribution of reinforcement/tokens as they might
inadvertently have a damaging impact on its efficacy (Petry
& Bohn, 2003). Again, a congratulatory approach was seen
as the appropriate one.
It was also emphasized that, despite some of the excit-
ing findings, contingency management programs were not a
substitute for counseling, but an adjunct to it. In terms of the
cessation of alcohol or drug use, reinforcements strengthen
behaviors that lead to abstinence. Counselors have a valuable
therapeutic opportunity to explore with their patients what
actions they took to refrain from using substances and then
utilize this information to clarify and develop the patientTs
coping techniques and strategies. As has been noted else-
where (Morral, Iguchi, & Belding, 1999), it is important to
clarify which techniques patients are using to maintain ab-
stinence, as some will have a greater likelihood of being
sustainable over the long run than others. For example, pa-
tients who are maintaining sobriety by isolating themselves
in their homes probably will not do as well as patients who
are practicing drug- and alcohol-refusal skills and creating
networks of nonsubstance-using friends (Morral et al., 1999).
This scientific presentation by Dr. Kellogg was com-
plemented with one by Ms. Marylee Burns from the Office
of Behavioral Health at HHC who spoke about how prog-
ress in the vocational domain could have a positive impact
on drug use and vice versa. This meant that reinforcements
used to change one kind of behavior could potentially im-
pact other behaviors as well. Papers on the use of con-
tingency management (i.e., Petry et al., 2000, 2001) were
also distributed to staff, and clinics were provided with
reassurances that the financial resources needed to make
these programs work would be made available.
6. Data collection
Information about the contingency plans, the reaction of
staff and patients, and the outcomes of the interventions
were ascertained from a variety of sources. Initial visits
and meetings with the administrators in each of the clinics
took place during the Summer of 2002. Each of the par-
ticipating programs submitted progress reports between
December, 2002 and February, 2003, and, during the
summer of 2003, Dr. Kellogg and Ms. Burns again visited
four clinics and met with staff, administrators, and, in one
case, patients. Other sources of information included letters
from patients and videotaped interviews with staff and
patients done in the fall of 2003.
In the Spring of 2004, the HHC made a decision to
expand the use of contingency management to additional
clinics as well. To help create enthusiasm and to facilitate
technology transfer, an in-house conference was organized
and all of the facilities and staff in the HHC system were
invited to attend. This conference was called, bScience in
the Trenches: Contingency Management at HHCQ and it was
held in June, 2004. This was a two-part conference that
included presentations by national experts on past and
current research on the use of contingency management in
addiction and other settings. In the afternoon presentation,
each of the five clinics had numerous members of their staff
describe their program, discussed the process of adoption,
and report on the response of the patients. This paper has
been based on information gathered from all of these
sources, and the quotes chosen for the text are those that
were felt to reflect the processes and themes that emerged as
salient in these dialogues and encounters.
7. Implementation
7.1. Reinforcement models
Although all adhered to the basic principles of reinforce-
ment, the five treatment sites differed in the models they
implemented. With the exception of Program 2, these were
all methadone treatment programs. In Program 1, each
patient received a piece of candy and a raffle ticket when
they attended a group. At the end of the group, there was a
raffle and the reinforcement/token was a $4 bMetro CardQ
(transportation card). Patients could also save their tickets
and use them, instead, in a raffle for larger reinforcement/
tokens. After attendance improved at the site, the program
created a series of benchmarks that included such topics
as achieving stable housing, demonstrating consistency in
attending the program, and improving skills connected to
activities of daily living. Patients were given reinforcements
for achieving these benchmarks as well. The program was
then further expanded to include reinforcing patients who
brought another patient to a group for the first time; patients
who had been promoted to the role of group leader were
rewarded by being taken out to dinner.
Program 2, which was a medication-free program,
combined the use of material reinforcements with social
reinforcements. This program focused, for the most part, on
patients who had recently entered treatment. They set three
criteria for reinforcement: (1) completion of all of the initial
assessments; (2) a week with one negative urine toxicology
report; or (3) a week with attendance at 80% or more of
scheduled groups. For the distribution of reinforcements,
the program used an expansion of their Monday morning
community meeting. The names of patients who had
achieved one of these criteria in the previous week were
announced and they were honored and applauded by the
staff and patients. In PetryTs intermittent reinforcement
model (Petry, 2000; Petry et al., 2000), patients received
prizes on some occasions and verbal reinforcements on
others. The impetus behind this ratio reinforcement model
was to reduce the cost of the intervention. Initially, Program
2 used this kind of model. Patients put their hand in a
bfishbowlQ and pulled out a chit. Some of these could be
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–6560

5. turned in for prizes, while others had bgood jobQ written
on them. This approach was found to be unpopular with
both patients and staff so the model was changed to one in
which every chit was worth a reinforcement/token of some
tangible value.
Not only were reinforcements given for meeting these
criteria, but also patients received reinforcement/tokens for
achieving such benchmarks as getting a GED, completing
training, getting a job, and keeping a job. These Monday
morning meetings turned out to be very dramatic and emo-
tional events, and they were well attended by both patients
and staff. As the Director reported, this community ap-
proach had a number of benefits: (a) it helped create a
positive atmosphere; (b) it brought the whole clinic—staff
and patients—together; (c) it served to model progress in
recovery for newer patients; and (d) it acknowledged and
affirmed the progress that clients had made. Patients would
frequently discuss these meetings, and they were looked
upon with great anticipation. Lastly, this clinic also used
reinforcement/tokens in an ad hoc way to help engage very
isolated and disconnected patients.
Program 3 focused on vocational issues. Patients re-
ceived a reinforcement/token after attending each vocational
group. When they had completed a cycle of four vocational
groups, they received a $25 gift certificate for a department
store. They received a similar certificate when they com-
pleted the 8-week cycle. In addition, McDonaldTs certifi-
cates were given to patients after submitting five totally
negative toxicology reports.
Program 4 developed an interactive computer program
that played an integral role in their system. Patients received
points for each group that they attended and these points
could be cashed in for reinforcement/tokens. At the end of
each day, counselors provided the names of all of the patients
who had attended groups and a designated staff member
entered the data into the system. The next day, patients could
log in and see how many points they had. The computer
provided information on the kind of gift certificates that
were available and a history of how they had used their points
in the past. When the patients were ready to cash in their
points, the staff member in charge of the data entry assisted
them in finding the best store to purchase what they wanted.
She even helped them look through the paper for sales.
Program 5 reinforced behaviors associated with voca-
tional and educational involvement, clinic attendance, group
attendance, and the achievement of treatment goals. The
primary focus, however, was on encouraging patients to
attend a vocational or GED class. Each time they attended a
session, they received $5 in an escrow account. After they
attended their fifth class, they were given a $25 gift cer-
tificate. A visual chart was created for each patient, and they
received a notation (check/star) for the date they attended
a group. This also served to give them a visual representa-
tion of their progress.
For other benchmarks, patients, initially, were given
recognition at the quarterly celebrations. Again, wrestling
with the brewardQ vs. breinforcementQ issue, the program
was planning to change this model in order to provide rein-
forcements that were closer in time to the manifestation of
the desired behavior.
7.2. Reinforcements distributed
The actual reinforcements used included movie passes,
transportation vouchers (bmetro cardsQ), McDonaldTs cou-
pons, calendars, gift certificates for major department stores
and music outlets, date books, tools, clothes, books, T-shirts,
microwaves, water bottles, sunglasses, things for children,
toiletries, food, and candy. Programs also instituted or ex-
panded upon award ceremonies. Across sites, receiving a
certificate or a reinforcement for gains made in their re-
covery could be a very emotional experience with numerous
reports of patients bursting into tears.
7.3. Process considerations
The interactions at the clinics between the staff and the
leadership were complex and exciting. In some ways, the
clinics were quite different from each other; however, certain
concerns and themes kept re-emerging. A central concern
was that not all patients would be treated bfairlyQ; that is,
have equal access to reinforcements. This seemed to be less
of an issue with the mechanics of the proposed plan, and
more a reflection of the empathic connection of the coun-
selors with their patients. The importance of enabling as
many patients as possible to be eligible for reinforcements
was reflected in the final plans developed by the clinics.
Dynamic program leadership was essential to successful
implementation. In each of the five clinics where a positive
reinforcement program was actually implemented (two treat-
ment facilities did not develop a program), there was a di-
rector who put his or her authority behind it, and who
consistently pushed the staff to make the program a reality.
The process of creating and initiating these programs
was met with resistance. As Backer and David (1995) noted
in their comments on technology transfer, bchange is hardQ
(p. 263). This may particularly be the case when the treat-
ment strategy is contingency management. As Petry and
Bohn (2003) have observed, many people oppose contin-
gency management until they see its impact on the patients;
once they see that, their attitudes begin to change.
This same process appeared to be at work in the HHC
clinics. Typically, the counseling staff were the last to bsign
onQ to the idea. Factors such as philosophical differences,
a fear that it would add to their workload, a sense of ex-
haustion and burnout, or a combination of all of these may
have contributed to this resistance.
Two processes appeared to combat this and to seemed
to contribute to the eventual staff endorsement of the
approach. The first was that the clinic leadership typically
organized a number of meetings in which feelings and
issues related to the use of reinforcements were aired and
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–65 61

6. explored. The Director of Program 1 described the events
in his clinic:
bThis was a long and hard process and there were lots of
fights. Staff saw it as a negative at first. . . As the Director,
I allowed staff to ventilate. The vocational rehabilitation
counselors started the whole process because their orientation
is far more receptive to this kind of thing.Q
The second process was that once some of the patients
began to earn reinforcements, others began raising the issue,
with some urgency, with their counselors. When initially re-
sistant staff saw the impact it was having on their clients,
many came to believe in its value.
8. Patient, staff, and clinic experiences
8.1. Patient experiences
As noted above, patients were very enthusiastic about
the program. Some initially met the idea that they would get
a reinforcement/token for attending a group with disbelief;
they had to actually see the reinforcement/token before they
would believe that it was not a trick. The staff reported that
they believed that the patientsT self-esteem was rising and
that they were becoming more empowered. They based this
view on their observation that there were improvements in
the patientsT appearance, and that the patients began to
speak about pursuing goals—typically of a vocational or
educational nature. Clients were saying. . .
bIn Russia, we were forced into treatment–Now (crying),
my God, ITm getting treatment and $25.00!Q (Program 2)
A core issue here was the profound emotional and
economic deprivation that these patients had experienced
and continued to experience. The reinforcements may have
been powerful because some came to believe through the
reinforcements that the staff cared about them. Staff be-
lieved that the reinforcements got them to the groups and
motivated them to stay, and then the power of the group
began to have its impact, as has been observed elsewhere
(Petry et al., 2001).
Patients who participated in the clinics that offered rein-
forcement programs often began to become more socially
integrated. First, their sense of connection to the program
grew and they participated more freely in its events.
bThe staff have heard clients say that they had come to
realize that there are rewards just in being with each other
in group. There are so many traumatized and sexually
abused patients who are only told negative things. So, when
they hear something good—that helps to build their self-
esteem and ego. (Program 4 Director) As one patient put
it, dI used to think the drug dealer cared for me, but this is
really caring.TQ (Program 4 counselor)
In a number of poignant stories, patients used their
department store gift certificates to buy presents or needed
items for their children or other family members. In a number
of cases, these actions began a process of reconciliation.
(See also Petry & Bohn, 2003, for a similar story.)
Lastly, patients began to connect more with each other.
In some clinics, patients who earned coupons for movies
would go together in groups. There were also reports that
patients in some programs were beginning to take care of
each other and give each other gifts.
As noted above, an internalization process took place in
which patients took increasing ownership and responsibility
for the program. As the Director from Program 1 put it, they
went from bYou are forcing meQ to bI choose.Q
In one striking example, patients from Program 1 who
felt that methadone initially made them drowsy delayed
the taking of their medication until after their group so
that they could be more alert and participatory. Addi-
tionally, in a reflection of their new perspective on their
recovery and the value of their program, clients began to
speak privately with their counselors regarding individuals
in the program who were engaged in activities considered
to be antithetical to their recovery. This kind of report-
ing was something that the staff said that they had never
seen before.
8.2. Counselor experience
Once the counseling staff overcame their resistance,
many benefited from it. Counselors said that they loved it
and that it was energizing and exciting. Morale was greatly
improved for staff as their enthusiasm grew.
bIt gives me a great deal of pleasure to know ITm part of a
state of the art methadone treatment program.Q (Program 1
supervisor)
An important part of this transformation was their changed
perspective on the reinforcements themselves. Instead of see-
ing them as a bbribe,Q
bWe came to see that we need to reward people where
rewards in their lives were few and far between. We use
the rewards as a clinical tool—not as bribery—but for re-
cognition. The really profound rewards will come later.Q
(Program 2 psychologist)
The staff and the administrators told us that their morale
was improved when they began to see increases in at-
tendance at their groups. Larger groups were easier to run
and more gratifying than those with small numbers. In
addition, when patients publicly, and sometimes tearfully,
acknowledged the counselorTs help, the staff felt a sense
of gratitude.
bIn the last two award ceremonies, clients said, dI want to
thank the staff. . . .T That sounded real good—we feel
appreciated.Q (Program 1 counselor)
Another counselor from Program 1 said: bNow, thereTs
no need for coercion, no more contracts. ThereTs more a
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–6562

7. sense of the clients volunteering. Before we felt like jailers,
now weTre looked at differently. . .Q
Many staff appeared to take the positive reinforcement
approach to heart. Instead of being critical and confronting,
they began to affirm and celebrate even small steps in the
right direction. In what could be seen as an example of
bgradualismQ (Kellogg, 2003), patients were given rein-
forcements by some counselors as they reduced their drug
use and worked towards abstinence.
I felt resistant at first. . . But, as it caught on, I began liking
giving points to clients. I saw that my client wasnTt using
dope, only coke, and ITd say—give him a point! So, now
ITm very involved. (Program 4 counselor)
Staff members were also inspired when patients who had
a long history of being alienated and treatment-resistant
responded to the program. In one report, Program 2 staff
told the story of a very bshakyQ client with a long history of
drug use and treatment failure. When he returned to their
program, they gave him a reinforcement every day he came
to the clinic for the first month. The patient was completely
taken with this; he could not stop talking about the things
that they had given him. At the time the staff presented this
story, he had been in treatment for 3 months. In Program 3, a
man with a chronic alcohol problem cried when he received
a McDonaldTs coupon. He said that no one had ever given
him anything for working on his recovery. After this, he
achieved sobriety for the first time in 8 years. These sorts of
bturn aroundsQ were clearly gratifying to the counselors and
made them feel that their job was worthwhile.
Lastly, relationships among the different staff services
(counseling, vocational, nursing) improved.
bLast year, the staff were not positive. They were very
territorial, and somebody was always waiting to attack this
idea. Perhaps they were feeling very threatened. . . Now, the
staff are more cohesive.Q (Program 1 Director)
bVarious disciplines like vocational rehabilitation and
activity therapy have become an integral part of the
program. There has been a major acceptance now for
vocational counseling and activities, and we now have a
dWall of Fame.’ [A bulletin board with pictures of employed
patients.]Q (Program 1 Director)
9. Impact on programs
9.1. Outcomes
There were two methadone programs in which it was
possible to get some quantitative data as to the impact of
the approach. While this data was not necessarily collected
with the rigor of a formal research project, it is presented
here for illustrative purposes. As noted above, Program 5
was particularly focused on the use of incentives to en-
courage vocational and educational involvement. Part of this
process included asking patients to attend groups based on
a five-session career development program. The program
was focused on preparing participants to find, get, and keep
a job by helping them discover their interests, values, and
strengths, by building their confidence to look for work, and
by coaching them in ways to successfully deal with work
stressors. The vocational counselors at Program 5 sought to
evaluate the effectiveness of this intervention. Because the
career counseling series had been in place for a year, they
were able to compare the intervention group with an his-
torical control group that did not receive the reinforcements.
The results showed that the incentive group was more likely
to complete the five 2-hr vocational training modules,
and, at 6-month follow-up, they were more likely to be
bvocationally engaged,Q which included such activities as
having a job, being involved in training, attending school,
or being seriously involved in a job search. As noted else-
where, the leadership at this program was very gratified by
these outcomes.
Other results came from Program 4, which developed
a point system for attending groups and taking recovery-
or vocationally-oriented steps. This was tracked over a
10-month period of time. Of the 408 patients who were in
the program during that period, 100 received two or more
reinforcements. The other 308 did not participate (typically
because of work or family responsibilities) or only received
one reinforcement. In terms of the number of days per
month in which a patient received a reinforcement, the mean
was 4.8 in month 1 and 6.8 in month 10. The peak was in
month 9 when they averaged 7.6 days. In short, these
patients were attending groups or engaging in recovery-
oriented behaviors 1 to 2 days per week.
Over time, the mean number of reinforcements that
each patient received when they did earn one, also increased
over time; from 5.2 in month 1 to 12.0 in month 10. The
exact meaning of these increases is unclear; they could
reflect better group attendance, more recovery-oriented ac-
tions, a growing willingness of counselors to use reinforce-
ments to shape positive behavior, or a combination of all of
these factors.
Looking across all of the programs, the kinds of im-
provements that staff and administrators reported in-
volved increased attendance at group and individual
sessions (including individual and group vocational ses-
sions), more drug-free urine toxicologies, increased com-
pletion of vocational training, more jobs, and more
attending school.
9.2. Changes in clinic mood and culture
Through this process, some of the clinics began to de-
fine themselves differently. One methadone clinic began
to truly see itself as a brecovery program,Q not just as a
methadone distribution center. They were happy that they
were beginning to get a reputation as an methadone
treatment program that was bserious about recovery.Q
S.H. Kellogg et al. / Journal of Substance Abuse Treatment 28 (2005) 57–65 63

8. Another unexpected, yet welcome, result was the marked
decrease in conflict and disruptive behavior in some of
the clinics.
bThe mood has changed in the last 6 months—there has
been less disciplinary action—in fact, no fights at all. There
has been no need for escorting people out of the building as
has been the case in the past.Q (Program 1 Director)
bI think it does strengthen the alliance with the team, not
just one counselor. The program has become nurturing.Q
(Counselors and Director in Program 3)
9.3. Follow-up
At one-year follow-up, the program was generally quite
popular among both patients and staff. The Coordinator of
Vocational Services at Program 5 noted:
bThere are three clinics here and 700 patients. It will take us
some more time to fully implement the contingency
management program as desired. We are on the right track,
though, and we saw some unbelievable results in our
vocational groups.Q
10. Perspectives and limitations
This intervention, differed from some of the classic
contingency management protocols (i.e., Higgins et al.,
2002; Petry et al., 2000; Silverman et al., 1996) in two
important ways. The first was that this was not an add-on
to an existing program; it became the centerpiece for all of
the psychosocial treatments. The second important differ-
ence was that the reinforcement system itself was, for the
most part, devised and run by the counselors and line staff.
They saw, first hand, the power of this kind of behavioral
technology, and they directly reaped the benefits of it in the
form of greater professional success.
We are greatly aware of the limitations of this work.
Clearly, it is more of a story than a study. Nonetheless,
something remarkable appears to have happened in these
clinics that can be a source of inspiration to other pro-
grams that are considering adoption of a contingency
management approach. Looking back on this experience,
it seems that a foundation for success was established
through the efforts that HHC and OASAS made to
improve treatment. Contingency management then acted
as a catalyst that connected the patients to the program
and animated the whole system. In addition, the successes
involved the coming together of the forces discussed
above. There was funding, a focus on improving treat-
ment outcomes for a large portion of the patient base
served by HHC, a scientific and clinical paradigm and
framework, leadership support on-site and on the execu-
tive level, and the creativity, enthusiasm and interest of
staff. Perhaps it would also be fair to say that the sixth
force was the appreciation for, and the embracing of, the
initiative by the patients.
Acknowledgments
Portions of the paper were presented as talks on
December 5, 2003, at the 14th
Annual American Academy
of Addiction Psychiatry Meeting in New Orleans, LA, on
January 26, 2004 at the 7th
Annual Conference of the
Alcoholism and Substance Abuse Providers of New York
State held in New York City, on July 12, 2004 at the
Translating Research into Practice Conference in Wash-
ington, DC, and at the Science in the Trenches conference
in New York, June 21, 2004. It was also presented as a
poster at The College on Problems of Drug Dependence,
66th
Annual Scientific Meeting, San Juan, Puerto Rico, on
June 14, 2004.
The authors would like to thank the following individ-
uals for their assistance in the development and implemen-
tation of this project: Michael Norman Haynes and Antonio
Webb in the HHC Office of Behavioral Health; Ludwig
Hauser and the staff at the Bellevue Hospital Methadone
Treatment Program; Jamie Rosario and the staff at the
Coney Island Chemical Dependency Treatment Program;
Martin Gaffney and the staff at the Elmhurst Hospital
Methadone Treatment Program; Aisha Muhammad, Curtis
Saunders, and the staff at the Harlem Hospital Methadone
Treatment Program; and Janet Aiyeku, Dayo Alalade, and
the staff at the Kings County Hospital Methadone Treatment
Program. We would also like to thank Elizabeth Oosterhuis
for her assistance.
Scott KelloggTs efforts were supported, in part, by NIDA
grants P60-DA05130 and DA 13046-04. He would also like
to thank John Rotrosen for his assistance and support.
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