Study enrollment will occur starting in September 2023 and will continue through 2026. Veterans who are referred to RRC are subject to an eligibility screening via phone, during which time they must ensure that they are 18 years of age or older, hold veteran status, are deemed not suicidal by RRC staff, and will participate in individual counseling. Eligible veterans are then assigned an intake session time, during which they show any requested documentation, complete the standard RRC intake form, complete an initial mental health assessment, and go through the informed consent process with RRC staff. Any participant who does not want to participate in the study will still receive all services as usual. After a participant gives consent, they are enrolled in the study and complete additional intake questions via the Qualtrics platform. Randomization will be done through the Qualtrics platform, so that results can be communicated to veterans immediately during their intake session. Randomization odds will be 50-50. The investigators plan to enroll 600 individuals, of which approximately 300 individuals will be offered financial incentives for therapy.
The experimental portion of these procedures is the random assignment of individuals to be offered or to not be offered financial incentives for therapy. The treatment group will be offered a $500 gift card for completing 6, 12, and 18 counseling sessions; up to $1,500 in total. Because RRC's typical practice involves prescribing and scheduling counseling in 6-session blocks, the financial awards are revealed to veterans in the treatment group in stages. After intake, treatment group individuals are told that they will receive a $500 gift card for completing the first 6 sessions; later sessions and awards are not mentioned. If the counselor decides that another 6-session block should be prescribed, then at the completion of the 5th session (i) the next 6 sessions are scheduled (i.e., sessions 7 through 12) and (ii) the counselor reveals that the participant can earn another $500 for completing the 12th session. The same process takes place during session 11. As part of RRC's typical practice, no veterans are offered more than 18 sessions. The counseling received by the control group is identical to that of the treatment group, as is the scheduling of additional sessions.
During the consent process, participants consent to be followed in administrative records. The investigators will track several outcomes of interest as they become available using several sources:
1. A start-of-session mental health survey administered via Qualtrics. This survey pre-dates our study and is part of RRC's usual process.
2. An end-of-session survey on expected benefits and expected costs of continuing counseling administered via Qualtrics. These questions were designed by the researchers.
3. Clinical mental health screenings performed by the licensed therapists after 6, 12, and 18 sessions. The practice of collecting this information pre-dates our study and is part of RRC's usual process.
At the point that 300 individuals are enrolled in the study sample, the investigators plan to estimate the treatment effect to determine the feasibility of adding a third study arm. If the treatment effect on either average number of sessions completed or the probability of completing six sessions is sufficiently large and there is support from RRC to do so, the investigators plan to begin randomizing into a second treatment arm which will receive a gift card of value less than $500. If this third study arm becomes a reality, power calculations will be re-evaluated to shift to an updated optimal sample size.
