What Is Contingency Management and How Is It Used in Addiction Treatment?Anna Ciulla
When you or a loved one enters treatment to overcome addiction, you want the best treatment available, one that’s evidence-based to be effective, and that offers the best prospects for a drug-free recovery. In connection with drug and alcohol rehab, one approach that may be used is contingency management (CM). While you may have heard of CM, you may not be familiar with the specifics of how it is used in addiction treatment.
DEFINITION OF CONTINGENCY MANAGEMENT
The simple definition of contingency management is reinforcing or rewarding a desired behavior. Considered relatively new in the field of substance abuse, CM is a form of behavioral therapy. CM “draws upon classic behavior modification theories” and includes the specification of a behavioral outcome that can be objectively measured.
An article published in Alcohol Research & Health states that CM is “the systematic reinforcement of desired behaviors and the withholding of reinforcement of punishment of undesired behaviors, is an effective strategy in the treatment of alcohol and other drug (AOD) disorders.”
HOW CONTINGENCY MANAGEMENT WORKS IN ADDICTION TREATMENT
When used in conjunction with addiction treatment, CM aims to motivate the addict to perform or engage in specific activities or adopt certain proactive behaviors. Reinforcement is a key term in contingency management, and the purpose for using CM in treatment for substance use disorder (SUD) is to help motivate and encourage pro-recovery behavior. This includes attending sessions, remaining abstinent, working towards specified career or vocational, educational, or social goals.
CM also involves the opposite of rewards, or consequences, for not complying with desired behavior or abandoning goals (including skipping treatment sessions, returning to drinking or drug use). This is known as operant conditioning.
Studies on CM and its use in addiction treatment and recovery have found that rewards work better for long-term effective sobriety than punishments. Thus, CM strategies have continually evolved to include the types of incentives and motivational enticements that fare better in treatment completion and long-term abstinence.
Examples of the types of reinforcements provided include incentives for:
- Attending therapy sessions, taking prescribed medications
- Remaining in treatment and reducing substance use (as evidenced by drug-free urine specimen).
- Researchers found that providing vouchers for individual behavioral therapy contingent upon abstinence to cocaine-dependent outpatients resulted in the CM group remaining in treatment significantly longer and reduced their use of cocaine relative to the outpatient group going to 12-Step meetings.
- A subsequent study found that 75 percent of those outpatients completing treatment (compared to another group not offered vouchers and receiving the same behavioral treatment).
- Another study involving outpatients undergoing buprenorphine dose-taper for opioid detoxification, found that 53 percent of the dose-taper group also receiving behavioral treatment (a voucher incentive program for opioid-free urine samples and verified participation in therapeutic activities) completed treatment and had better 16-week treatment outcomes than the 20 percent dose-taper group combined with standard treatment completing treatment, and had lower 16-week treatment outcomes.
- Engaging in prosocial behaviors in a clinic
- Complying with goal-related activities – such as going to a doctor for a goal that involves health improvement, filling out an application for a job when securing employment is the goal, involving a child in an activity together if parenting is the goal.
- Attending 12-Step or self-help meetings
- A 2001 study published in the Journal of Substance Abuse Treatment found that the most-frequently chosen incentive activities for compliance with non-drug activities for those in substance use treatment included those involving sobriety (such as attending Alcoholics Anonymous meetings and completing worksheets).
- Recreational or leisure activities
- Researchers also found that vouchers for recreational activities (like going to the movies or library or church) were effective in achieving patient compliance in non-drug activities during substance use treatment.
HOW INCENTIVES WORK TO PROMOTE PRO-RECOVERY BEHAVIOR
Given that the pull of motivation to do something (in exchange for some type of reward) is more effective in addiction treatment than punishment for failure to comply, there is no single reward that universally generates enthusiasm and proactive behavior. Researchers continue to test several types of rewards or incentives to gauge their effectiveness with certain populations and/or in the treatment of specific addictions.
Vouchers are an example of contingency management reward. Yet, the vouchers may be for distinctly different rewards. For example, a voucher may consist of movie tickets, a spa day, or some other form of free goods and services. Cash is another reward or incentive that motivates behavior compliance, at least initially. This type of incentive is particularly attractive to those with limited finances. The long-term use of incentives, however, does not result in continued proactive behavior. The most effective use of CM is in the early part of treatment, to give the recovering addict the opportunity to gain self-confidence participating in pro-recovery behavior and activities. The idea is that treatment, including psychotherapy (individual and group), different treatment modalities, educational instruction, lifestyle modification counseling, evidence-based and recovery-oriented therapies, participation in 12-Step and self-help groups, recreational and leisure activities and creating a relapse prevention plan provide a solid foundation in recovery so that the addict can become internally motivated to remain abstinent and engage in proactive recovery behavior.
A 2015 study published in the journal Drug and Alcohol Dependence found that low-cost CM cash incentives, when coupled with outpatient reinforcement-based treatment for substance abuse increased treatment attendance, treatment session attendance and continuing treatment utilization in the subsequent month, compared with patients receiving only reinforcement-based treatment. Participants were given $10 to return to treatment the day after intake assessment, and $15 for attending treatment on the fifth treatment day.
Researchers found that the use of vouchers or prizes in contingency management for cocaine- or heroin-dependent outpatients receiving substance abuse treatment in community treatment centers remained longer in treatment and experienced greater verified periods of abstinence than patients receiving standard treatment alone. Thus, the study confirmed that vouchers and opportunity to win prizes are equally effective for compliance with abstinence goals and for long-term positive treatment outcomes.
EFFECTIVENESS OF CONTINGENCY MANAGEMENT IN TREATMENT-RELATED OUTCOMES
According to clinical research trials, the use of CM in conjunction with addiction treatment for alcoholism and illicit drug use has proven effective in reducing drug use, improving compliance in taking prescribed medications, in remaining in treatment, and promoting participation in other treatment-related goals, including employment. Studies also found that using various reinforcers across different populations and targeting various behaviors “generally improves outcomes relative to comparison treatment.”
A 2018 study concluded that CM interventions both motivate and maintain drug abstinence by providing the drug user with earlier, more salient and more predictable positive consequences for abstaining from drugs.
A meta-analysis of study findings in 2006 found that CM is “among the more effective approaches to promoting abstinence during the treatment of substance use disorders,” by improving clients’ ability to remain abstinent and paving the way for them to more fully experience the other components of clinical treatment.
If you or a loved one is seeking addiction treatment from a trusted rehab facility that employs evidence-based practices, please contact one of our Beach House admissions counselors today.