Contingency self-management- a new approach to
Addiction using Carecreds with mobile phone prompting
Dr Michael D’Souza MD FRCGP FFPHM
Contingency Self-management is a new approach to help people with all types of addiction. It is based
on the proposition that addiction has hitherto been so difficult to treat because sufferers have to gain release from four
locked in states. The first is due to a chronic personality state that is perversely and adversely reinforced by ordinary
clinical care. The second is a chemical craving to obtain the Dopamine rewards generated by their addiction. The third is
the stress relief also produced by the addiction. The fourth is entrapment in a subculture of fellow users that infect, prompt
recidivism and provide the supplies and financial basis for its continuation.
idea is to offer a Carecreds service, which has already been shown to help the majority of severe opiate users, via premium
number mobile phone support. This will provide a self-funded, contingency management service to reinforce patient resolve
to break each of these locks. We believe that such a service is worth testing to see if it is both more effective and less
expensive than current approaches.
It is recognized that Addiction is one of
the principal causes of modern disease and when extreme can generate widespread social distress. We know that a wide range
of activities such as perversions and gambling can become addictive and many totally different substances such as food, tobacco,
alcohol and opiates seem to be much more liable to cause it than others. There are abundant psychological theories about its
causes and many approaches to preventing and controlling it. Yet until recently it has been a mystery as to how behavior that
is essentially so self-destructive can override the basic animal instinct to survive. In the UK, on the naïve assumption
that it is prompted by willful criminality, we currently spend over £10 billion a year on imprisoning addicts ignoring
the fact that even legally irresponsible experimental animals can become addicted. Yet it increasingly
clear that this ill-conceived policy is not only ineffective and wasteful but may actually be counterproductive. Sadly the
£2 billion we spend on the humane alternative of treating addiction clinically also has a poor success record and as
a consequence, a large part of the £93 billion spent on the NHS is devoted to picking up the pieces of our failure to
treat addiction satisfactorily.
last five years there have been some interesting developments. Brain research has at last identified that probably all causes
of addiction stimulate the direct production of larger amounts of central Dopamine. This hormone is responsible for generating
pleasure and most importantly of directing motivation in all higher animal life. Indeed experimental rodents will
starve to death rather than stop pressing a lever that delivers them central dopamine rewards. Clearly this helps explain
the self-destructiveness seen in severe human addicts.
because human beings possess such exceptional intellect, people with addiction also can exhibit changes in their personalities
i.e. the role their consciousness assumes when conversing with itself and with its fellow men. This usually
manifests itself as inappropriate and uncooperative thought or behavior such as crime and poor social bonding.
Interestingly recovered addicts describe the only thing that helped them was when they “hit
rock bottom” and changed their own dependant behavior so that they began caring more for themselves and others. The
idea behind this paper is that it is now possible link all these different observations and to devise a new approach to addiction
that might have a better chance of success. It is perhaps useful to explain how we have arrived at our present conclusions
of what this treatment should be.
2005 disheartened by the difficulty of getting effective help for our severely addicted Class A addicts in General Practice,
we instinctively felt that relying on a non-judgmental approach to persuade them to adopt a healthier low stress lifestyle
might, in the circumstances, be the best we could do. Although it proved clinically challenging to engage with these patients,
just taking just this simple measure did seem to calm and then alter their personality state and produced much more encouraging
results than referring them on to local services. It seemed that when engaging in a long-term (>9 month) non-judgmental
adult dialogue, our addicts began adopting an adult personality state themselves and it was this that produced the beneficial
effects. It was as if the really basic position that has evolved for the purpose of survival is to co-operate
with ones social group from which stems trusting and moral behavior etc. The personality problems and addiction were pathological
responses to stress.
We then came
across one clinical intervention that had been consistently reported by the literature as being really useful in controlling
addictive behavior. This was Contingency Management (i.e. the provision of rewards contingent on improved behavior). Furthermore,
although advocated as being effective by NICE, it was not in widespread use in the UK. The reason seemed to be that many experts
felt it was a conceptually undesirable form of bribery that tended to encourage patients who had no desire to be helped to
become manipulative and dependent on these rewards for self-gain, furthermore there was little evidence about how long the
period incentives should be kept up and they also had considerable anxiety that the media would be very critical of spending
NHS resources on rewarding “blameworthy” addicts.
HOW CARECREDS HAVE EVOLVED
Notwithstanding these objections, indeed accepting that they might be the reverse of treating patients as adults, in
2009 we designed and got some modest local funding to try a comprehensive form of Contingency management, which incentivized
our patients to do a range of self-caring activities such as exercise and relaxation and to social re-integrate via caring
for others. The idea was to use this approach for just a short time on poorly motivated patients. We called our scheme “CareCreds”
and we offered participating patients earnings related store (Boots) vouchers i.e. they increased in value in proportion to
the number of CareCreds gained. We were very gratified with results and after 18 months over 87% of our patients had become
street clean. See the full results as published on the NICE website. Last year the scheme won the GP magazine award for clinical innovation. However,
possibly because of the "bribery objection" it did not receive any further public funding until 2012. Therefore
in the intervening period we have met these objections by devising a new version of the scheme that requires a much more adult
approach and operates on all degrees and all forms of addiction.
call our new scheme Contingency self-management because the process is entirely under the control of the addicted person.
Indeed we now suspect that ordinary clinical care does not work as well as it should precisely because, particularly kindly
relationships, accidentally encourage such patients to stay in a dependent personality state. Although it is clear that addiction is linked with many things that are difficult to change such as
genetic inheritance and misfortune, it is equally clear that many people with similar genes and even worse luck do not develop
damaging habits. It is also evident that there are many addicts who recover quite quickly. Why not everyone? The key difference
seems that persistent addicts get caught up in a world of recurrent major or minor pleasurable experiences to which they are
constantly chemically prompted to return. Their experience is that both their personality state and their use of addiction
enables them to avoid remembered or recurrent stress; even the stress of the guilt of being an addict! Sadly it achieves this
in an effective but disastrous way. Because they get such a powerful relief from stress many addicts panic about whether can
survive without maintaining their addiction. It is a way of thinking similar to Obsessional Compulsive Disorder, somewhat
irrational but the more it is done the easier the habit is to repeat. However it is mainly because they have unconsciously
escaped irksome reality by entering into this parallel, usually immature, personality state they pursue a “selfish”
life narrative that seeks this instant gratification rather than help. In this way any locally available addictive substance
or learned behavior can become their poison of "choice".
summarize they have become triple locked in by personality problems, stress relief and pleasure seeking motivation. Furthermore
for some others further entrapment is possible. Because their addictive behavior often starts as a reaction to stressful trauma,
such as bereavement, shame or exclusion from normal community life, it may drive them into a subculture of fellow addicts.
Indeed such a community may have introduced them to addiction in the first place. After a time “the friends” in
this subculture are all they have left and they mutually support and finance their shared addictive lifestyle. With four or
more locks on the door it is clear now why addiction is so difficult to escape.
self-management has been redesigned to tackle addiction on the basis of this theory. It is open to anyone with any form of
addiction who feels that they are harming themselves or others. It explains to them what they are up against
and then how they can use Carecreds to unpick as many of these four locks, as they need to by themselves, in confidence, in
their own time and without any externally generated pressure. It
is surprising how sometimes even small incentives produce big changes. Like the last straw that breaks the camel's back they
can create a tipping point that suddenly results in change.
Tackling the first lock i.e. being
in the wrong frame of mind is the most important and most challenging. CareCreds incentivizes adherents to self-manage by helping them remain in an adult, cooperative personality state rather than remaining
regressed state and feeling like “a patient” or a victim of addiction. Unlike Alcoholics anonymous it opposes
meaningless self-labeling like “I am an alcoholic”. Instead it encourages them to be positive
about themselves and their capabilities. This is aided by our having a dialogue only with their adult side and enlisting
this to help others.
To help with the chemical predicament the second lock initially
we ignore the addiction itself but focus on reducing stress by developing healthier life habits, problem solving and financial
control. Only then does the scheme incentivize addiction reduction using delaying tactics in response to cravings to allow
spontaneous hormonal adjustment. It uses regular mobile phone texting
rather than face-to-face contact. This allows their phone number to be
used as their sole identity. This maintains complete confidentiality and lack of embarrassment in participating throughout
the period of self-treatment. The duration of which (or if necessary recommencing a course of treatment) is entirely up to
each participant. Furthermore there is little or no
financial barrier to using the service. Because the main cost is only text messaging this can be provided
for just a token cost while each person sees if Carecreds actually helps him or her. Only then and only
if they want to, they can put extra pressure on themselves by paying in a more realistic stake via a premium phone
number. This should be a variable stake (e.g. based on 5% of their monthly addiction costs), which they can then try to earn
back by gaining sufficient CareCreds.
for making patients aware of ECBC (Earn Credit By Caring)
With the agreement of local commissioners ALL GPs are sent an ECBC pack of explanatory forms with attached
plastic cards with our contact website, email and mobile contact number. They can hand these out to patients with ANY sort
of harmful addiction but particularly to those who are not doing well. These leaflets can be offered to distressed family
members who are paying for the habits of unmotivated relatives as a useful tool to introduce an element of earning into their
relationship, pointing out the section relevant to them.
Plastic Card that Patients to carry has on it
Instant Yoga instructions etc
Contact info. Website; email and our 5 premium
The handout leaflet text
you have ever wished, like most people, for a chance of losing your addictions, improving your relationships, finding more
peace, self-respect and a means of being more use to yourself and others, then please read further about ECBC (Earn Credit
by Caring). This is a proven way you can help yourself get free and deserve to be so. ECBC will give you the confidential
support you require to do this via a non- judgmental service.
ECBC is self-directed treatment aimed
getting you to reduce your own stress as the best way of escaping addiction. To participate, all you need to do is contact
us by text. The act of doing this enables you to put up a small financial stake via our premium number, most of which you
can soon earn back by acquiring sufficient CareCreds*. We suggest you start by using our lowest (25p) rate. However, the higher
you make your stake the more it will increase your resolve to help yourself. Indeed many people prefer eventually to increase
their stake so that approaches 5% of their monthly addiction costs because this then becomes a useful way of accumulating
savings at the same time as they reducing the costs of their habit.
you are helping someone else
If you do not have a problem yourself but are financially supporting
a friend or relative who does, we suggest that rather than continually giving them handouts you offer to subsidized them (at
least in part) according to how many Carecreds they earn each month. This system operates by you choosing the premium rate
phone to use. The weekly contact texts enquiring about CareCred earnings are sent to both your mobile phone and the patients.
Your replies will validate the claims and be converted into CareCreds earned. At the end of each month you are at liberty
to move up or down the premium rating or to stop if you feel it is not helping or that the patient is ready to do DIY CareCreds."
*CARECREDS ARE EARNED by
1. Safe eating 5/day + Food of calorific strength averaging 1cal/1gm
Exercising body daily till SOB/sweat provided it
is medically OK to do so
3. Exercising mind – skill courses, crosswords, reading arts & science in the media
4. Exercising emotion flexibility to more easily adopt an adult frame of mind
5. Not damaging others
6. Not damaging yourself
7. Not using tobacco
8. Practicing Safe sex
9. Safe alcohol use
Following medical advice
addictive habits on own – delaying responses to craving
12. Undergoing a planned cure
13. Stopping addictive practices
14. Helping research
15. Helping others
16. One CareCred is automatically added for each consecutive month that ECBC is continued to a maximum
of 3 months
total you can gradually earn a combined total of 95 CareCreds. This is equivalent to getting 95% of your monthly stake back.
The minimum of 5% that is retained by ECBC is to cover the running costs of the scheme and to fund “Free” CareCred
earnings for some cases, who are very impoverished and considered to be so stuck that they need some start up encouragement
to participate.There is an option for relatives,friends or services to pay and supervise this service. In this option the
carer's mobile will contact the premium number and their while the patients number will also be contacted via a free service.
Only the carers' record of earned CareCreds will be used for repayment.
N.B. All our contact with you will be handled confidentially and anonymously in that only your mobile phone number
will identify you. This number will be used to text you weekly both to give you support and to prompt you to report back on
how many Carecreds you are earning.
So START OFF BY TEXTING US NOW using the word - CareCreds - followed by an estimate about how much your addiction
actually cost you to the nearest pound yesterday.
E.g. if it cost £5 Text to the premium
number of your choice: Carecreds5
N.B. If you're not troubled by the financial cost of your addiction
but only by shame it causes,
We suggest you text the daily amount you would
be prepared to pay to remove this embarrassment.