Contingency Management

Understand how contingency management works and how it can help people with a substance use disorder
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It's not a therapy unto itself but rather an evidence-based behavior modification intervention.

When people are rewarded for positive behavior, they're likely to repeat that behavior in the future. This is referred to as operant conditioning—a type of learning where behavior can be modified when reinforced in a positive and supportive manner. The rationale is that incentives or rewards will motivate individuals to try harder. It's the reason employers use bonuses to reward top performers and parents give their kids an allowance for doing chores. In addiction treatment programs, this kind of reward or incentive is called contingency management (CM). The CM approach (also referred to as motivational incentives, the prize method, or the carrot-and-stick method) can be highly effective in treating substance use disorders.

We asked clinicians at the Hazelden Betty Ford Foundation to explain this approach and its relationship to substance abuse disorders and treatment.

How Does Contingency Management Work in Reinforcing Drug Abstinence?

When it comes to treating individuals with substance use disorders (once commonly referred to as drug abuse or substance abuse disorders), research shows that CM works. According to the National Institute on Drug Abuse, "Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs." The principles behind voucher-based reinforcement and prize incentives promote abstinence from benzodiazepines, cocaine, opiates, alcohol, marijuana and methamphetamine. Additional documented research shows that, when combined with medication, CM is a highly effective behavioral intervention for individuals struggling with opioid use disorders. One of the most commonly targeted behaviors in addiction treatment is attendance—in both residential and outpatient rehab environments, and individual and group settings. If patients are on time for the first group of the day and for the workshops after lunch, their names are entered into a drawing the following day to have the opportunity to win a "carnival prize" (candy, chips, etc.) or a gift certificate. The incentive is compounded—they not only need to be on time to be entered into the next day's drawing, but they also have to be on time the next day. If they're not present and on time, they don't win.

How Does Contingency Management Differ from Other Therapy Approaches in Substance Abuse Treatment?

CM provides incentives to achieve goals. It's not a therapy unto itself but rather an evidence-based behavior modification intervention. Positive behavior is rewarded through vouchers and prize-drawings. While motivational incentives can help individuals achieve their treatment goals, this method should be used in conjunction with another approach, such as cognitive behavioral therapy (CBT). CBT can help a person address their thoughts and feelings, eventually phasing out unhealthy thought patterns.

How Would You Respond to Criticism that Contingency Management Encourages Artificial Incentives Is Too Expensive or that Those with Substance Use Disorders will lose Motivation Once Certain Reinforcers Are No Longer Offered?

Any behavior changes made by patients that can improve their chances of successful recovery outcomes are not "artificial." Even if individuals are showing up only for the chance to win, they are still choosing to be there. When the behavior they're working to change is attendance, their choice to be there on time proves the incentive is working.

Regarding cost, you can use a wide variety of low-cost prizes and incentives. It really doesn't matter if the prize is just a fun-size candy bar—clients are excited to have the chance to be recognized while having a little bit of fun.

According to the National Institutes of Health, "In a number of studies, individuals who earlier received contingency management continue to benefit even after tangible reinforcement is no longer available. The longest duration of abstinence achieved during treatment is a robust and consistent predictor of long-term abstinence."

Further research shows CM can be a powerful tool for teaching people that they are able to change their behavior when they're sufficiently motivated. This applies to all aspects of life. Success in a task like showing up on time can lead to success in more complex tasks. Motivational incentives can also help participants build confidence over time, counteracting feelings of shame or low self-esteem.

Is Offering an Incentive for a Drug-Free Urine Sample One Way to Utilize Contingency Management?

The majority of CM treatments for substance use disorders reinforce positive changes without punishing unmet expectations. Rewarding a drug-free urine sample might aim to decrease using behavior but, in the context of addiction treatment, could easily become punitive—creating an uncomfortable environment that leads a person to drop out. Those in treatment may have experienced past trauma associated with punishment or emotional pain, contributing to their addiction. According to the American Society of Addiction Medicine, "Drug testing should be used as a tool for supporting recovery rather than exacting punishment. Every effort should be made to persuade patients that drug testing is a therapeutic, rather than punitive, component of treatment. If drug testing is used in a way that creates an "us vs. them" mentality, it is at odds with the therapeutic alliance."

Reward systems create a much more positive environment. For example, when a group achieves 100 percent attendance in a week, the group leader could bring in donuts or coffee for everyone. This simple act motivates people to attend.

Are there Certain Skills Required When Delivering this Approach?

One of the most important skills in delivering CM is being able to effectively communicate behavior expectations and work with patients to make sure they clearly understand those expectations.

Is Contingency Management Helpful for Those Struggling with Mental Health Issues and Substance Use Disorders (Co-occurring Disorders)?

According to a study published in the Journal of Dual Diagnosis, "dual diagnosis patients involved in contingency management-based care attended scheduled treatment sessions more than 50 percent more often than the patients not involved in contingency management-based care." 

When there's motivation to change behavior, there's an increased likelihood that patients will stay active in their treatment programs. That's a win-win for everyone.

Contingency management is just one approach used in treatment and recovery from alcohol or other drug addictions. A quality treatment provider will employ a number of different evidence-based therapies, including Twelve Step Facilitation.

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