Process improvement for behavioral health

Use Motivational Incentives


Many clients need additional incentives to attend assessment, intake, and treatment sessions.


Offer positive reinforcement or rewards to reinforce the desired behavior and to help motivate clients to stay in treatment long enough to experience sobriety.

Featured Stories

During Treatment

Mid-Columbia Center for Living in The Dalles, Oregon increased continuation from 46 percent to 73 percent by giving clients a $10 gift certificate after the fourth treatment session and by throwing a pizza party to celebrate every four sessions in which the group achieved 100 percent attendance. For more information, see the Mid-Columba change bulletin.

New York City Health and Hospitals Corporation programs in New York, New York offered individualized motivational incentives, which helped increase retention from 55 to 66 percent, treatment completion from 29 to 36 percent, and increased the number of clients who maintained employment from 15 to 24. The behavior for which incentives were given changed over time; once clients reached a treatment goal, they were offered an incentive for something else. They offered incentives that would help clients return to work and develop life skills such as gift certificates to stores where they could buy clothes they needed for job interviews. For more information see NYC Health and Hospitals Summary of Motivational Incentive Programs. See supporting materials, including Cumberland Diagnosis & Treatment Center brochureLincoln Recovery Center program materials, and Woodhull program materials and attendance card.

During Transitions

Palladia, Inc. in New York, New York reduced no-shows for outpatient intake appointments from 50 percent to zero by giving rewards—additional time for their weekend passes—to residential clients at their Esperanza halfway house who attended the outpatient intake appointment prior to discharge. For more information about other changes that Palladia made, see Palladia’s case study.

For Staff

Signal Behavioral Health Network in Denver, Colorado offered financial incentives to individual counselors—$25 for each client who continued from detoxification to residential treatment within 30 days and stayed for at least 14 days.

The Jackie Nitschke Center in Green Bay, Wisconsin used punch cards to reward staff for increased access and retention. For every outpatient client who called and started within 4 days of the call, a punch was made on a punch card. When 10 punch cards were complete, all staff received 4 hours of time off with pay. This reinforced staff answering phones to engage and encourage clients to start treatment and giving information consistently. They used another punch card a year later for cognitive mapping. Once each counselor had 7 punches, one for each type of cognitive mapping, they received a box of chocolates. It helped identify who needed more training. Since then, they have found that building relationships with employees, giving staff positive feedback, and using the Nominal Group Technique have been effective ways of motivating staff to make changes.

Daybreak Youth Services in Spokane, Washington gave staff bonuses for productivity, based on billable hours.

Lessons Learned

  • Offer individualized incentives and/or group incentives.
  • Select rewards that are related to the behavior you want to reinforce, for example, gift certificates at stores that will help clients dress appropriately for job interviews.
  • Local businesses may be willing to donate rewards.
  • Inexpensive rewards such as bravery certificates for beginning treatment or recognition certificates for staying in treatment for a specified time period, can also be effective.
  • Determine at what point clients most often drop out of treatment—for example, between the first and second treatment sessions, etc.—and plan rewards that focus on remaining in treatment beyond that period.
  • Offer staff motivational incentives for successful process improvements.

Tracking Measures

Cycle Measure

  • No-show rate to assessment appointment or treatment sessions
  • Percentage of referred clients who were admitted

Data Collection Form



  • 1. Select a group or transition point that has poor attendance.
  • 2. Depending on the aim you’re focusing on, collect baseline data for:
    • No-show rate for the selected group
    • Percentage of referred clients who were admitted
  • 3. Decide what behavior you want to reinforce, for example, attendance at group, orientation session, or at next level of care.
  • 4. Decide what incentives you will offer. (Anticipate the cost to make sure you have funds to cover it.)


  • 5. Announce the motivational incentive program to clients.
  • 6. When the clients have met the requirements, create a celebration around the distribution of the rewards or prizes.
  • 7. After two weeks, re-calculate the no-show rate or percentage of referred clients who were admitted for the clients who participated in the incentive program.


  • 8. Check the fidelity of the change. Was the change implemented as planned?
  • 9. Evaluate the change:
    • Were clients interested and motivated by the incentives that were offered?
    • What other incentives would clients like to have?
    • How did staff members react to using motivational incentives during treatment?
    • Depending on the aim you’re focusing on:
      • Did the no-show rate in the selected group decrease after incentives were offered?
      • Did the percentage of clients who were admitted to the next level of care increase?
    • Did the number of admissions increase?


  • 10. Adjust the incentive or the expected behavior and re-test this promising practice for an additional two weeks.

Repeat this series of steps until you have designed a motivational incentive program that reinforces desired behaviors and helps engage clients in treatment.

More Stories

During Treatment

Daybreak Youth Services in Spokane, Washington rewarded groups with 90 percent attendance with a pizza party. For more information, see the Daybreak change bulletin.

Fayette Companies in Peoria, Illinois gave a one-dollar voucher for each of the first seven days in residential treatment to congratulate the client for achieving another day toward recovery. At the end of the first week, the vouchers could be exchanged for a seven-dollar gift certificate to a local discount store. When patients moved through the phases of treatment, they drew from a fishbowl for prizes such as gift certificates to a bookstore or to take a peer from the program to lunch.

Axis 1 in Barnwell, South Carolina offered incentive programs to clients in the women’s treatment program attending group three times a week. Each time a woman attended the group, she put her name in a jar. At the end of every month, a name was drawn, and the winner got to choose a small prize from an assortment of gift items. Each quarter, one name was drawn; that person got to choose a larger gift. If a client missed two consecutive groups, her name was removed from the jar and she had to start over. This incentive has been a big hit with the women in the group. For more information, see the Axis 1 case study.

The Families First program at TERROS, Inc. in Phoenix, Arizona increased homework completion from 10-30 percent to 85 percent. Clients remembered to bring their notebooks, required for written assignments 80 percent of the time instead of 10-20 percent of the time. Initially they implemented a formal contingency management program. Later they changed the plan to lower the cost and to better match the clients’ needs—clients referred by child protective services, homeless clients from shelters, and clients who were non-compliant in other groups. They found that clients got too upset when there was a chance of winning, but they didn’t win a prize. Instead of having a drawing, clients received TERROS bucks for attendance, which they could use to buy small prizes including food, hygiene items, and toys, as well as medium-sized prizes such as DVDs. For more information, see the TERROS Families First development plan.

The Indian School Ladder program at TERROS, Inc. in Phoenix, Arizona increased participation in the first half of the year from 31 percent in 2004 to 71 percent in 2005, slipping a little to 62.4 percent in 2006. The second half of the year had consistently lower attendance rates that they attributed to the hot summer months and holidays later in the year. Attendance was 49.6 percent in the second half of 2005 and 47 percent in the second half of 2006. They implemented the more formal fishbowl method to draw prizes based on outpatient attendance. There were four classes of rewards in the fishbowl: 250 “sorry no prize”; 200 small one-dollar prizes including personal care items, candy, soda, soap, toothpaste, and detergent; 49 medium-sized prizes worth $20-$25 including electronics, games, clock radios; and, 1 grand prize such as a DVD player, bike or stereo. The prizes cost $665 each month. Clients got to draw for a small prize if they attended all groups on the first day of treatment. They got to draw for up to two prizes if they attended two entire consecutive days, up to three prizes if they attended three full consecutive days, and up to five prizes if they attended five full consecutive days. If they missed a session, they had to restart at one draw again at their next session. For more information, see a graph of the results and the McDowell SuperStars Program.

During Transitions

Fayette Companies in Peoria, Illinois gave clients an amethyst stone when they proved that they were connected to outpatient care.

Alcohol & Drug Recovery Services of Saint Joseph Hospital in Marshfield, Wisconsin gave residential clients who attended an outpatient intake appointment prior to discharge, the choice of a copy of the Alcoholics Anonymous or Narcotics Anonymous book.