What Is Contingency Management?
Contingency management (CM), often called motivational incentives, is a type of behavioral therapy rooted in the basis of operant conditioning. This type of treatment provides rewards for the desired behaviors such as clean drug tests. At times, disciplinary measures or withholding of privileges may be taken when the client engages in an undesirable behavior.
CM has been shown to be effective for a range of issues including impulsive behaviors, defiance, and substance abuse.
As client needs vary, CM can fit those needs through slight modification. CM can be used as a stand-alone treatment or in combination with many other treatment styles, including:
- Cognitive-behavioral therapy.
- Medication management.
- Medication maintenance programs for people in recovery.
- Motivational interviewing.
History and Theoretical Basis
Operant conditioning is an aspect central to behaviorism, which is a theoretical style of psychology popular throughout the mid-1900s. The style is widely used and valued today. The basic idea is that:
- Behaviors that are rewarded are more likely to continue and continue with increased frequency, intensity, and duration.
- Behaviors that are punished are more likely to be reduced in frequency, intensity, and duration until they are eliminated.
- Behaviors that are ignored, given no reinforcement, or no punishment will be reduced until eliminated.
Operant conditioning believes that many behaviors are learned through this process. It can modify established behaviors or teach new behaviors through rewards or punishments.
Touching a hot stove provides a negative reinforcement that reduces future occurrences. Eating ice cream gives a reward that will increase occurrence. Training a rat to push a button by rewarding him with food is also operant conditioning.
Operant conditioning and contingency management programs are used in many settings that benefit from structure and expected responses, including schools, prison, behavioral health centers, and residential treatment facilities.
Contingency Management and Substance Use
People in recovery that enter a CM substance use program will have the opportunity to be rewarded for desirable behaviors.
Contingency management works under the belief that substance use is influenced heavily by social, environmental, and biological factors. On a number of levels, substance use creates a rewarding experience for the user. The experienced high or excitement surrounding the use outweighs all else. This is illustrated by continued desire to use in the face of harm and negative consequences that transpire as a result.
Someone entering recovery must choose to move away from substance use. Unfortunately, those new to recovery may have to face strained relationships, poor financial situations, and ailing mental and physical health resulting from the substance abuse. This new situation is not rewarding and will be seen as a punishment for sobriety.
People in recovery that enter a CM substance use program will have the opportunity to be rewarded for desirable behaviors. If they attend treatment, maintain expectations of the program, and avoid unwanted behaviors, the chances of rewards grow. Ideally, the reinforcement gained from the CM program will equal or outweigh the perceived reward associated with drug use.CM has been proven effective for treatment of:
Although punishments also work to reduce unwanted behaviors, CM programs generally will utilize this consequence sparingly because:
- Punishment damages the relationship between the person giving the consequence and the person receiving it. This is problematic in a therapeutic setting.
- Punishment is related to lack of engagement and consistency in treatment and recovery.
- Punishment and fear of punishment inspire a secrecy that adversely impacts recovery.
Any CM program will need to focus on 7 principles to guide treatment and diminish substance use behaviors.
1. Target behavior. The first issue works to identify the target behavior. This can either be a negative behavior to be reduced or a positive behavior to be increased. The negative behaviors will be associated with substance use like buying or using, and the positive behaviors will be healthy substitutions. These positive target behaviors could be compliance with sessions, working towards sobriety goals, and establishing appropriate relationships.
2. Choice of target population. Some clients in recovery will not need or want to participate because they have enough intrinsic motivation to progress in treatment. CM will be more useful for new clients or those with poor rates of success in the past.
3. Choice of reinforcer. The reinforcer is the central aspect of a CM program. If a person in recovery is rewarded with an item that has no interest to them, it will not accomplish the goal. What is a reward for one person may have no value to another. The therapist and client will work to establish a reward that is desirable and realistic. Money has been a successful reinforcer but not appropriate in all cases, as it can trigger cravings.
4. Incentive magnitude. If a CM program had unlimited resources, they could reward short periods of sobriety with expensive electronics, cars, or houses. In reality, CM programs work to find the balance between what is practical and what is rewarding. Some people may need higher levels to remain engaged. Aspects to consider include:
- Past use.
- Past success with recovery.
- Strength of social supports.
- Past response to rewards.
5. Frequency of incentive distribution. Some programs will reinforce the desired behavior each time it occurs, at a specified rate, or at a variable rate in an attempt to receive the most benefit. The ideal rate will differ according to the specific needs of the client.
6. Timing of incentive. The timing is as important as the frequency. The best case scenario is for the reward to be given immediately after the desired behavior is completed. This helps to build a strong association between the wanted behavior and the reward.
7. Duration of intervention. How long should the CM continue? The goal is that the desire for sobriety will continue when the rewards are removed. This will take longer for some people than it will for others. The decision to end the reinforcement will coincide with relapse prevention strategies to reduce risk of relapse.
Other Important Features
The seven principles are crucial, but they may not create recovery on their own. Since many people use substances to increase their feelings of pleasure, CM treatments will benefit from being an environment that fosters positivity. By completing this, the program will reduce the ambivalence the person in recovery feels by offering a sense of caring, affirmation, and encouragement.
Variations of Contingency Management
Two main varieties of CM programs exist: voucher-based reinforcement (VBR) and prize incentives contingency management.
In VBR, the person in recovery will receive one voucher for each urine sample provided that does not contain a drug of abuse. The value of the voucher is low initially. Over time, the worth increases to provide a greater desire to provide the sample and sense of accomplishment for testing clean. Once enough vouchers are collected, they can be exchanged for desirable items, food, and activities. The added benefit is that these rewards help promote an active, social, drug-free lifestyle.
With prize incentives CM, the client will earn the ability to select prizes from a bowl by providing urine samples, attending treatment, taking medication as prescribed, and other wanted positive behaviors. The prizes will be written on a piece of paper with values up to a specific number like $100. The more desired behaviors the client performs, the better their chances for a larger prize.
Barriers and Criticisms
Critics of CM believe that it is not the best intervention to treat addiction and dependence. See below for common criticisms and responses to those criticisms:
Criticism: It is too expensive.
Response: Research shows that an average cost of $200 per client is necessary, but it can drastically improve outcomes.
Criticism: It encourages gambling.
Response: Though prize incentives treatment has an aspect of gambling, research has shown no association to gambling addiction.
Criticism: It does not get to the root of substance use.
Response: Behaviorism believes that there is no need to identify or process the underlying cause of substance use. Behaviorists note that insight does not change behavior, so only the behaviors need to be addressed.
Criticism: It is too restrictive.
Response: CM works well with other types of treatment and can be done concurrently.
Accessing Contingency Management Treatment
Many treatment programs will implement aspects of contingency management in their practices. The availability of full CM treatment will vary largely by area. The use of CM is expanding, as the National Institute on Drug Abuse is advocating for its utilization based on the track record of success.
Asking for contingency management by name will help screen potential providers. If you’d like to find a program that incorporates contingency management or any other type of therapy, call 1-888-744-0069 to speak with a treatment support advisor today.