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Contingency management involves rewarding individuals for positive behaviors during substance use disorder treatment. There is a great deal of evidence to indicate its effectiveness, showing improvements in abstinence and treatment retention. [1]
- Contingency management is a reward-based treatment to help people reduce addictive behaviors and improve their treatment engagement.
- It can be implemented in any treatment setting, such as inpatient or outpatient treatments, methadone clinics, and partial hospitalization programs.
- Different treatment providers will offer a range of treatment approaches so it can be helpful to contact them directly to find out more about their available programs.
What is contingency management?
Contingency management (CM) is a type of behavioral therapy that helps people to alter their behaviors through positive reinforcement. Rewards are given when positive behaviors are demonstrated, such as vouchers for retail items or services. [2]
CM is based on operant conditioning, developed by B.F. Skinner in 1937. Operant conditioning states that behaviors can be adapted or controlled based on consequences and reinforcements. [3]
CM uses this evidence-based technique to help people with substance use disorders (SUDs) change their addictive behaviors and improve their motivation to stay in treatment. [4]
It is common for people with substance use issues to experience changing levels of motivation and some ambivalence around their sobriety, which is often one of the main reasons for treatment nonadherence, dropouts, and possibly relapse. CM can help improve adherence by promoting change and positive behaviors with rewards. [4][5]
First, a behavior will be identified, such as abstaining from the substance, attending treatment sessions, or medication compliance. This behavior will be easily identifiable and quantifiable so that when it occurs, a reward is given, and when it does not, the reward is withheld. [6]
Usually, one behavior will be adapted at a time, so the individual has the opportunity to receive rewards regularly and is not overwhelmed with numerous changes at once, which may set them up to fail. [6]
How it works: Voucher-based reinforcement
CM can be provided via a voucher-based reinforcement program or a prize incentives program. Voucher-based reinforcement involves being rewarded with vouchers of different monetary values for food, shopping, or entertainment. The value of these vouchers might start small and be increased as the individual repeatedly engages in the targeted behaviors (for example abstinence or attendance). [2]
Prize incentive programs may involve the individual being rewarded with a number of draws from the ‘fishbowl’ to receive a prize. This could be cash or gift vouchers of ranging values, such as from $1 to $100. With longer treatment engagement or abstinence, the number of draws the individual is rewarded with might increase, leading to a greater number of prizes. [9]
Contingency management in addiction treatment
CM can be utilized in a range of treatment settings, although the targeted behaviors may differ. These programs can be implemented in inpatient, outpatient, partial hospitalization, or intensive outpatient programs to reinforce positive behaviors. [4][5] It may be beneficial for these rewards to be given in group settings so others can witness their peers winning prizes and vouchers, thereby providing more incentives to succeed. [9]
For example, in outpatient treatment, it may be difficult to monitor drug abstinence as this would require regular testing. As such, CM might be focused on attendance rather than abstinence. [7]
In contrast, people in inpatient treatment or partial hospitalization programs could be tested several times a week. As such, they can be rewarded for periods of abstinence, with rewards increasing in value as the duration of abstinence increases. [6]
CM has been found effective in any treatment setting, regardless of the individual’s characteristics or health issues. [5][8]
What to expect in contingency management programs
CM programs will vary depending on the setting in which they are implemented and the individual’s treatment needs. However, most programs will involve certain expectations of the individual, such as: [2][4]
- Signing a contract that details expected behaviors, such as abstinence or attending sessions, and the rewards they can expect to receive for engaging in these behaviors.
- Regular testing, which may be every few days.
- Engaging in other treatments, such as cognitive behavioral therapy (CBT), to manage underlying causes and emotional issues and learn positive coping strategies.
- Maintained abstinence, improved treatment engagement, and increased motivation.
Benefits of contingency management
CM can be one of the most effective treatment interventions in treating SUDs. A meta-analysis of various treatments found that CM was the most effective intervention for abstinence and treatment retention among SUDs. [1][10]
Another study found that treatment retention was higher among the CM group than the standard care group, with 49% completing a 12-week program in the CM group, compared to 35% in the standard care group. It also demonstrated that abstinence was around four times higher in the CM group than in standard care (18.7% vs. 4.9%). [11][12]
Other benefits of CM include: [2][4][7]
- By rewarding abstinence, people are more motivated to maintain sobriety
- Providing goals to work toward and a sense of achievement when goals are met, which reinforces the behavior
- Significant reductions in drug use
- Improved adherence to and outcomes of other treatments
- Ability to implement CM in any treatment setting and within the home environment
Limitations and ethical considerations in contingency management
Some professionals and individuals consider ethical issues and limitations of CM to include: [2][8][12]
- Believing it is not effective and therefore they won’t use these strategies within their treatment plans
- High costs of providing rewards, regular testing, and clinician time
- It does not address the underlying causes of substance use
- External rewards impact intrinsic behavior – the individual only changes their behavior to receive the reward but does not internally desire the changes, suggesting that once the reward is removed, the negative behavior returns
- CM programs that involve negative punishments harm therapeutic relationships, are not liked by clinicians or patients, and increase dropout rates
However, these issues are mostly found to be opinions or myths and can be contradicted by the range of research and evidence that shows the benefits of CM. [1][2][12]
Getting started with contingency management
When looking for a treatment center, there are several things to consider, including the severity and type of substance use, the type of treatment that is required, and the costs of treatment. After finding appropriate treatment providers, it may be beneficial to contact them directly to ask about their specific treatment approaches and whether they provide CM alongside other interventions.
