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Contingency Management

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Individuals who struggle with addiction and want to enter treatment may be curious about the types of therapies they might receive in rehab. A comprehensive addiction treatment plan may include a variety of therapies that can vary depending on your specific needs, treatment goals, and the substance you use. One of these therapies may be contingency management, an evidence-based therapy that can help you start and remain on the path to recovery from substance misuse.

This article will help you understand what contingency management is, contingency management theory and interventions, how contingency management is used to treat substance use disorders (SUDs), and how to find treatment and rehab that offers contingency management therapy.

What Is Contingency Management?

Contingency management (CM), also sometimes referred to as motivational incentives, is a form of behavioral therapy based on operant conditioning principles, which involves receiving incentives for desirable behaviors.1 An incentive is a type of reward, such as a voucher that can be exchanged for tangible goods (like movie passes or retail goods) or draws for prizes, that a person in addiction treatment receives when they achieve positive outcomes, such as clean drug tests or a certain period of sobriety.2 If target behaviors are not met, the incentive is withheld.3

Addiction is a chronic yet treatable brain disease characterized by compulsive, uncontrolled substance use despite significant negative consequences, and part of overcoming addiction involves changing deeply rooted behaviors.4 This is why much of addiction treatment involves behavioral therapies like contingency management.4 Research has demonstrated that CM is effective for treating SUDs because it is based on defined, attainable short- and long-term goals and focuses on helping people make positive behavioral changes.3

While contingency management can be implemented as a standalone therapy, it is often used in combination with other forms of behavioral therapy, like cognitive behavioral therapy (CBT) or motivational interviewing (MI); and it can also be used in conjunction with medications for addiction treatment.5

The National Institute on Drug Abuse (NIDA) explains that treatment needs to address the whole person not just the use of drugs of alcohol, which is one of the reasons treatment professionals often offer several types of therapy and, if necessary, medications, depending on the substance a person uses.4 It’s important to note that the specific therapies a person receives can depend on their unique needs and situation.

History and Theoretical Basis

Contingency management theory is based on the idea of operant conditioning, a type of learning process that is associated with psychologist B.F. Skinner, who coined the term in 1937.6 Operant conditioning is a learning process where behavior is determined by the consequences associated with that behavior.6 One of the main concepts behind operant conditioning is that voluntary behaviors that are rewarded are more likely to be repeated, and behaviors that are punished are more likely to be extinguished; a behavior that is repeated becomes a habit.6, 7

Principles of operant conditioning may be used in a wide range of settings as a way of increasing desired behaviors and outcomes, including treatment attendance and medication compliance.7 Settings where operant conditioning principles and/or contingency management may be used can include prisons or correctional facilities, schools, behavioral health centers, residential/inpatient treatment facilities, parenting and teaching classes, and even medical and physical therapy practices that treat chronic pain problems.7, 8, 9, 10

Contingency Management for the Treatment of Substance Use Disorders

Medical professionals diagnose addiction as a substance use disorder (SUD). According to the American Society of Addiction Medicine (ASAM), addiction is a treatable, chronic medical disorder that involves a complex interaction between brain circuits, genetics, the environment, and a person’s life experiences.11 People with SUDs engage in compulsive substance use and other harmful behaviors despite the negative impact this has on their lives.11

The CM approach sees alcohol or drug misuse as a form of learned, operant behavior, which is partly reinforced by the biological and chemical effects of substances, as well as by environmental influences such as peer pressure.7 One of the foundational ideas of CM is that behavior change is possible as long as there is consistent reinforcement of the target behavior.7

People who use alcohol or drugs often experience a sense of pleasure and reward from using substances. If they stop using the substance, they may no longer feel pleasure or reward. In this way, CM may be helpful in breaking the cycle of addiction by providing rewards for desirable, healthy behaviors and withholding rewards for negative or unhealthy behaviors, such as ongoing substance use.3

Behaviors related to SUD treatment that might be rewarded in CM can include:10

  • Attending scheduled treatment sessions.
  • Attending mutual support groups, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).
  • Taking medications as prescribed.
  • Participating in recovery activities.
  • Avoiding substance use.
  • Having negative drug tests.

Research has shown that incentive-based interventions like CM are effective for increasing treatment retention, increasing medication compliance, and promoting abstinence from drugs and alcohol.7, 12

There is strong evidence supporting the use of CM to reduce the use of stimulants like methamphetamine or cocaine.3 In a study comparing the effects of CM versus standard care for people struggling with stimulant misuse, researchers found that 49% of the contingency management group completed 12 weeks of treatment, compared to just 35% of the group receiving standard treatment.12

CM is useful for people addicted to other substances as well. Other studies have found similar beneficial results for decreasing opioid, alcohol, marijuana, and benzodiazepine use, reinforcing medication compliance, and encouraging people to attend treatment sessions.7, 12

The 7 Core Principles of Contingency Management

CM is based on principles of behavioral analysis.12 It involves 7 core principles, which include:13

1. The target behavior

This refers to the specific behavior or outcome, referred to as a “target.” A target can be a negative drug test or another desirable behavior.

2. The target population

This refers to the specific person or people in a treatment program who will receive the specific reinforcement. Not everyone in a treatment program will be working on the same goals at the same time.

3. The type of incentive

This refers to the specific reward or reinforcement that is provided for the desired outcome. It should be chosen based on what the target population would prefer to receive. It can include vouchers and access to specific privileges at the rehab (such as preferred times for appointments or parking spots). One well-known reinforcement intervention is known as the “fishbowl method.” This involves an intermittent reward schedule, where people who demonstrate the target behavior immediately draw a slip of paper and receive a prize from a selection kept at the rehab.

4. The magnitude or amount of reinforcement

This can be described as how much of the reward should be provided to achieve the target behavior.

5. The frequency of reinforcement distribution

This refers to how often the reward needs to be provided. It takes into account different variables, such as the target behavior, resources, the amount of clinical contact a provider has with their patients, and whether a behavior will be reinforced every time or only some of the time a behavior occurs.

6. The timing of reinforcement distribution

This means that the provision of reinforcement should ideally occur as close to the target behavior as possible.

7. The duration of reinforcement(s)

This refers to how long a person should receive the reinforcement in order to motivate the desired behavior.

Variations of Contingency Management Programs

Contingency management can involve specific types of interventions and take place in different programs and settings, depending on the desired outcome and target population.

For example, two examples of CM programs are the Abstinence CM and Attendance CM used by the U.S. Department of Veterans Affairs, which are designed to help veterans achieve abstinence from substances or increase attendance at group therapy sessions, respectively.14

In the Abstinence CM, veterans provide drug tests and updates on their recovery to their social worker; if they provide a negative screen, they immediately draw from a prize bowl containing prize slips in various denominations that can typically be exchanged at the Veteran Canteen Service.14 A veteran can draw one prize for the first negative urine test and continue to a cap of 8 with consistent abstinence.14

In the Attendance CM, the goal is to increase attendance, so veterans can receive rewards just for showing up to therapy sessions.14 This program works slightly differently than the Abstinence CM; it involves writing the names of veterans who attend sessions on a slip of paper and placing these names into a hat. If the veteran has an unexcused absence, their name is removed from the hat. At the beginning or end of the session, a certain number of names are pulled from the hat and vouchers for cash rewards are distributed accordingly.14 This method has been shown to increase attendance among veterans in treatment and increase their overall sense of accomplishment.14

The two main types of contingency management interventions include:1

  • Voucher-based reinforcement (VBR). This involves providing vouchers when a person achieves a target behavior. It is mainly used in adults who misuse opioids, alcohol, or both. The person receives a voucher for each negative drug screen; the voucher has a monetary value and can be exchanged for tangible goods, such as food, movie passes, or other items. In the beginning, the value of the voucher is low, but this increases over time with each consecutive negative drug test. If a person provides a positive test, the value is reset to zero.
  • Prize incentives contingency management. This is a similar approach to VBR, but it involves the opportunity to win cash prizes instead of vouchers. Individuals who provide negative drug tests, demonstrate consistent attendance, or complete goal-related activities have the chance to draw from a bowl to win a prize between $1-100. As with VBR, the number of draws starts with one and increases with consecutive negative drug tests, but resets to zero with a positive drug test.

Accessing Contingency Management Treatment

If you or someone you care about is struggling with addiction or substance misuse, you should know that treatment like contingency management can help you start the path to recovery and take back control of your life. Even if things seem bleak right now, there is always hope, and research has shown that CM can be a beneficial method for helping people achieve abstinence and stay in treatment.7

If you’re interested in finding a rehab near you, you can search the drugabuse.com directory for inpatient treatment or outpatient treatment centers located across the country. You can also instantly verify your insurance coverage for rehab and substance use disorder treatment. Call our free, confidential helpline at to speak with a caring admissions navigator about your rehab options and ask any questions you may have about treatment.

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Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS). During his time at JEMS, Ryan developed Mobile Integrated Healthcare in Action, a series of in-depth articles on Community Paramedicine programs across the country that go beyond transporting patients to emergency rooms and connects specific patients, such as repeat system users, the homeless and others with behavioral health issues and substance use disorders, to definitive long-term care and treatment. In his current capacity as Medical Editor for American Addiction Centers, Ryan works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.
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