171 by shimeiyan3


									Alcohol & Drug Abuse

Principles of Money Management
as a Therapy for Addiction
Marc I. Rosen, M.D.
Margaret Bailey, M.S.W.
Robert R. Rosenheck, M.D.

M      oney is a well-recognized cue
       for drug use (1). Several studies
have reported evidence of an increase
                                                approach has been developed as a ful-
                                                ly articulated intervention. One rea-
                                                son for the lack of well-defined mon-
                                                                                              The three T’s
                                                                                              Teller function
                                                                                              The teller function serves two basic
in substance abuse and in its adverse           ey management–based therapies is              purposes: to restrict the client’s access
effects around the beginning of the             that money management is often                to funds and thus prevent mis-
month, when income checks are typi-             thought of as an involuntary restric-         spending, and to ensure that essen-
cally received (2). In response to this         tion of liberty, more akin to criminal        tials—shelter, utilities, and food—are
observed connection between receipt             probation than to recovery-oriented           paid for. A money manager may me-
of funds and substance use, nonspe-             rehabilitation. Money management is           diate or restrict the client’s access to
cific money management interven-                frequently perceived as being coer-           funds through three basic arrange-
tions are often provided. A payee may           cive and adversarial and is thought to        ments.
be administratively mandated for                undermine patients’ autonomy (3). It             The first arrangement, and the one
beneficiaries of Social Security Dis-           is thus often seen as the direct an-          that most tightly restricts the client’s
ability Insurance, Supplemental Se-             tithesis of a recovery-oriented ap-           access to funds, is the establishment
curity Income, and veterans benefits.           proach to rehabilitation.                     of a bank account to which the mon-
Voluntary clinical interventions, such             A conceptualization of money man-          ey manager has exclusive access—for
as intensive case management, often             agement is needed that goes beyond            example, when a representative pay-
include money management as one of              the simple interruption of impulsive          ee maintains a bank account for a
several components in a broad service           spending to also emphasize the af-            client.
delivery package.                               firming, positive goals of money man-            Under the second type of arrange-
   Despite the frequent use of payee-           agement. A bank account can repre-            ment, the client voluntarily agrees
ship and money management compo-                sent control over one’s life and choic-       that his or her funds will be deposited
nents of case management, neither               es. Clients can use saved funds to re-        into another person’s or institution’s
                                                ward themselves when goals are                account. Some residential facilities
                                                achieved or can continue to save              adopt such an approach in that they
Dr. Rosen is staff psychiatrist at the De-      funds to achieve material representa-         receive clients’ checks, arrange for
partment of Veterans Affairs Connecticut        tion of their clinical progress.              immediate payment of rent, and store
Healthcare System in West Haven, Con-
                                                   We propose a conceptualization of          the remainder of the funds in a
necticut, and associate professor of psy-
chiatry at Yale University School of Med-
                                                money management as a specific                pooled account for payment of future
icine in New Haven. Ms. Bailey is direc-        therapy that targets drug addiction           expenses. The money manager tracks
tor of co-occurring disorders program-          and involves three functions. The first       the client’s balances in this pooled ac-
ming at Connecticut Mental Health Cen-          is an administrative—or “teller”—             count and accesses the account when
ter and clinical instructor in psychiatry at    function, whereby mismanagement               directed to do so by the client.
Yale University School of Medicine. Dr.         of funds is curtailed by controlling ac-         Under the third arrangement, the
Rosenheck is professor of psychiatry and        cess to the client’s bank account. The        client voluntarily gives the money
public health and director of the division      second function involves training the         manager a checkbook or a card for an
of mental health services and treatment         client to make a budget and plan ex-          automatic teller machine, thus par-
outcomes research in the department of          penditures. The third function incor-         tially limiting the client’s ability to ac-
psychiatry at Yale University School of
                                                porates behavioral principles by using        cess the account. The account re-
Medicine. Send correspondence to Dr.
Rosen at the VA Connecticut Healthcare
                                                discretionary spending to reinforce           mains in the client’s name, and the
System, Department of Psychiatry, 116A,         constructive activities and sobriety.         client writes all the checks. Clients
950 Campbell Avenue, West Haven, Con-           These three functions, listed in Table        are encouraged to establish a direct-
necticut 06516 (e-mail, marc.rosen@yale.        1, can be remembered as the “three            deposit account and to bring any oth-
edu). Sally L. Satel, M.D., is editor of this   T’s”—teller, training, and treatment-         er income to meetings with the mon-
column.                                         linked spending.                              ey manager so that the income can be
PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o February 2003 Vol. 54 No. 2                                     171
Table 1                                                                                       funds if predetermined treatment
The three functions of a money manager                                                        goals are met.
                                                                                                 Three important principles under-
Function       Goals of function           Implementation of function                         lie treatment-linked spending. First,
                                                                                              agreements or contracts between the
Teller         Restrict client’s access    Maintains account for the client that only
               to funds and ensure that    the money manager can access directly, or
                                                                                              client and the money manager are an
               essentials are paid for     stores clients’ funds until the client decides     explicit part of the therapy at the time
                                           when the funds are to be withdrawn, or             of enrollment. Second, contracting
                                           merely stores cards for automatic teller           involves not only withholding funds
                                           machines and checkbooks while the client           but also disbursing funds for client-
                                           maintains the account
                                                                                              directed purchases when goals are
Training       Help client to plan        Writes a plan for the coming month’s income         achieved. Third, the treatment goals
               and adhere to a budget     and expenditures on a worksheet. When               that are linked to spending are nego-
                                          “emergency” funds are requested, holds
                                          funds for 48 hours to allow further reflection      tiated between the client and the
                                          on the request. Reviews income and expen-           money manager. Treatment-linked
                                          ditures at the end of each month                    spending is similar to therapeutic
Treatment-     Reinforce abstinence        Weekly contract between the money manager          contracting (5) in that the client ne-
  linked       and abstinence-             and the client for the money manager to            gotiates the terms of the contracts.
  spending     promoting activities        disburse discretionary funds if achievement        Thus it differs from classical contin-
                                           of abstinence or of other abstinence-pro-          gency management.
                                           moting activity is verified
                                                                                                 Treatment-linked spending may in-
                                                                                              volve contracting directly around tox-
                                                                                              icology-verified abstinence or around
                                                                                              broader treatment goals, most of
mailed to the bank for deposit. This          client and the money manager antici-            which have at least an indirect con-
arrangement is less restrictive than          pates this situation by including an            nection to abstinence. A comprehen-
the first two, because the client re-         agreement that the client will allow            sive list of tasks is available in an arti-
tains access to his or her funds and          the money manager to put a two-day              cle by Petry and colleagues 2001 (6).
can simply go to the bank and make a          hold on access to discretionary funds           At least one activity should be a task
withdrawal.                                   if two conditions are met: the client           that is likely to be easily accom-
                                              suddenly wants funds that have not              plished. Money managers should se-
Training function                             been previously budgeted for, and the           lect easier tasks if clients fail at the
The training function provides collab-        case manager thinks the expenditures            initial task to ensure that clients expe-
orative guidance on money manage-             may not represent a positive use of             rience positive reinforcement (7). For
ment both under routine budgeting             funds. The hold is based on the pre-            example, a client who identifies a goal
circumstances and under “emer-                sumption that the impulse to spend              of making friends who abstain from
gency” or “high-pressure” circum-             needs further consideration to deter-           drugs might be reinforced for going
stances. Under routine, “low-pres-            mine whether the proposed expendi-              to a meal with one such friend (and
sure” circumstances, clients are              ture would undermine the achieve-               showing the money manager the re-
taught to budget their funds and to           ment of broader goals. The hold gives           ceipt for the meal). Failing that, the
plan their expenditures through a se-         the client time to reconsider whether           client might be given reinforcement
ries of worksheets that involve detail-       his or her request for funds might be           for making a list of potential friends
ing anticipated sources of income and         a result of drug craving or an ill-con-         who do not use drugs. In our experi-
expenses for the upcoming month. At           sidered impulse. If the client persists         ence with implementing this princi-
the end of the month, the clinician           in this request, the hold will be relin-        ple, clients often prefer to designate
and the client return to this work-           quished and the client will be given            these funds for a purpose that re-
sheet to review actual expenditures           access to the money.                            quires many weeks of saving. For
for the month and how they were                                                               some clients, simply tracking the
paid—for example, by check or by              Treatment-linked spending                       growth of savings toward a broadly
cash. The information from this re-           The third function—treatment-                   defined goal—for example, retire-
view is used to plan the budget for the       linked spending—is used to reinforce            ment—is itself reinforcing.
next month. The budget is signed by           abstinence and abstinence-promoting
the client and the money manager to           activities by building on procedures            Conclusions
indicate their agreement with the             used in contingency management in-              Money management need not be
plan.                                         terventions—that is, those in which             seen as a restrictive, adversarial inter-
   Under emergency or high-pressure           clients receive prizes or vouchers              vention but can be designed as a re-
circumstances, the client comes to            contingent on the achievement of                covery-oriented, skill-building en-
the case manager at an unscheduled            certain conditions set by the therapist         deavor. The three money manage-
time with an urgent need for funds.           (4). The client agrees to reward him-           ment functions—teller, training, and
The original contract between the             or herself from saved discretionary             treatment-linked spending—involve
172                                     PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o February 2003 Vol. 54 No. 2
                                                                                                    ed hospitalization among schizophrenic co-
fundamentally rehabilitative rather             feel coerced and devalued. Thus                     caine abusers: a government sponsored re-
than restrictive activities. There is           there is an urgent need for therapeu-               volving door? New England Journal of
now a pressing need to determine the            tic approaches that can help clients                Medicine 333:777–783, 1995
efficacy of money management as a               manage their funds. Money manage-                3. Brotman AW, Muller JJ: The therapist as
therapy, whether it be implemented              ment holds the promise of replacing                 representative payee. Hospital and Com-
                                                                                                    munity Psychiatry 41:167–171, 1990
as part of payeeship (8) or voluntarily.        spending for self-destructive drugs
On the basis of the principles out-             with spending that helps clients                 4. Higgins ST, Budney AJ, Bickel WK, et al:
                                                                                                    Incentives improve outcome in outpatient
lined, we have ourselves developed              achieve their chosen goals. o                       behavioral treatment of cocaine depend-
an intervention that we refer to as                                                                 ence. Archives of General Psychiatry 51:
ATM—advisor–teller–money manag-                 Acknowledgments                                     568–576, 1994
er—that has been successfully imple-            This research was supported in part by           5. Berglas S, Levendusky PG: Therapeutic
mented and is currently being tested            grants R01-DA12952 and P50-DA09241                  contract program: an individual-oriented
                                                from the National Institutes of Health, by          psychological treatment community. Psy-
in a clinical trial.                            the Department of Veterans Affairs Vet-             chotherapy 22:36–45, 1985
   Clients are harmed when funds                erans Integrated Service Network 1               6. Petry NM, Tedford J, Martin B: Reinforc-
that could be used to improve their             Mental Illness Research Education and               ing compliance with non-drug-related ac-
quality of life are used to buy drugs.          Clinical Care Center, and by a grant from           tivities. Journal of Substance Abuse Treat-
Furthermore, the fact that some dis-            VA Health Services Research and Devel-              ment 20:33–44, 2001
                                                opment.                                          7. Iguchi MY, Belding MA, Morral AR, et al:
ability income is spent to purchase
                                                                                                    Reinforcing operants other than abstinence
drugs undermines public support for             References                                          in drug abuse treatment: an effective alter-
vital programs that provide subsis-             1. O’Brien CP, Childress AR, McClellan T, et        native for reducing drug use. Journal of
tence incomes to disabled persons.                 al: Integrating systemic cue exposure with       Consulting and Clinical Psychology 65:
                                                   standard treatment in recovering drug-de-        421–428, 1997
One intuitive solution to this prob-
                                                   pendent patients. Addictive Behavior          8. Ries RK, Dyck DG: Representative payee
lem—simply restricting clients’ ac-                15:355–365, 1990                                 practices of community mental health cen-
cess to funds—may be of little use              2. Shaner A, Eckman TA, Roberts LJ, et al:          ters in Washington State. Psychiatric Ser-
and may merely serve to make clients               Disability income, cocaine use, and repeat-      vices 48:811–814, 1997

                       Submissions Invited for Child
                       & Adolescent Psychiatry Column
                       The editor of Psychiatric Services’ Child & Adolescent Psychiatry, Charles
                       Huffine, M.D., invites papers focusing on systems of care for children and ado-
                       lescents with serious and complex mental and behavioral disorders. In recent
                       years great progress has been made in developing methods of addressing serious
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                       to a broad mental health readership.
                         Dr. Huffine is soliciting reports of collaborative work on behalf of children’s
                       mental health among pediatric medical care systems, social service agencies, spe-
                       cial education programs, the juvenile justice system, drug and alcohol treatment
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                       scribe innovations in programming and new clinical methods to address the com-
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                       dren and adolescents. Papers should describe innovative clinical programs that
                       are mindful of contextual issues, training that prepares psychiatrists to work in
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