Contingency Management – Treating Substance Abuse
If you’ve been looking into substance abuse treatment options, you may have come across the term contingency management (CM). This approach may seem complex so you may be unsure about exactly what is contingency management. In this article, we’ll explain the theory behind this behavioral change strategy and discuss how it works in practice.
Contingency management or motivational incentives is based on operant conditioning – a learning process through which behavior is modified through reinforcement or punishment. It is used to promote positive behavioral change by rewarding or reinforcing the achievement of goals and withholding rewards or introducing punishment when behavior is undesirable.
The core principle is of this strategy is that people are more likely to do things that are reinforced or rewarded and less likely to continue in behaviors that are punished. Contingency management is typically used in addiction treatment programs that are at least three months long. This gives patients enough time to do the work to earn positive reinforcement.
CM can be used as a standalone treatment but addiction treatment professionals often recommend combining therapies for maximum effect. Therefore, some people may be offered a combination of CBT and contingency management or medication management, medication maintenance, motivational interviewing, or other interventions.
Assumptions Behind Contingency Management
CM is grounded in certain assumptions. One of them is operant conditioning which we mentioned earlier. This approach to learning was first described by B. F. Skinner. It theorizes that consequences shape behavior. Over time, people will increase behaviors that are followed by a reward and decrease those followed by punishment.
CM also assumes that:
- Addiction is reinforced by the rewarding effects of both the substance and the person’s environmental influences.
- It’s possible to achieve targeted behavioral change by systematically applying immediate and guaranteed rewards and consequences.
- Individuals can reduce substance use or become and remain abstinent as long as the rewards of a drug-free life are greater than the effects of drug use. They will also be able to initiate and maintain abstinence if the consequences of substance abuse are greater than any expected consequences of being drug-free.
The Principles That Guide Contingency Management Treatment
While CM programs vary from one provider to another, they all need to focus on seven principles to help individuals achieve and maintain sobriety. Let’s look at each of them.
1. Identifying the target behavior. Before any rewards or punishments can be instituted, both the participant and the therapist need to be clear on the behavior that is to be achieved. The aim could be to reduce negative behavior or increase positive behavior.
Negative behaviors typically include things like buying or using drugs or alcohol. The positive behaviors are usually healthy substitutions such as taking steps to reach sobriety goals and establishing healthy, sober relationships.
2. Choosing the target population. Not everyone needs CM. Some people in recovery have sufficient internal motivation to stick to their treatment programs and they don’t need a promise of vouchers or prizes to change their behavior.
Contingency management is better suited to people who have struggled to maintain their sobriety in the past or those at the very start of their sobriety journey.
3. Choosing the reinforcer or reward. Naturally, the reward needs to be something that the patient values and wants. Otherwise, contingency management won’t work. Since what is valuable for one person may be insignificant to another, CM has to be based on personalized recovery techniques. The therapist and the client need to work together to come up with realistic, meaningful rewards.
4. Determining the magnitude of the incentive. Contingency management programs have limited resources. Therefore, they can’t reward participants with fancy electronics or vehicles. Even though the rewards must be practical, some individuals need bigger incentives than others.
Therapists determine the size of the reward based on the individual’s history with substance use, their past success in recovery, their past response to rewards, and the strength of their support system.
5. Establishing the frequency of incentive distribution. Each program is different and each client has different needs. In some cases, the desired behavior is rewarded whenever it occurs. However, with some programs and clients, it is reinforced at either a specific rate or a variable rate depending on what would be most effective.
6. Determining the timing of the incentive. Ideally, the individual should receive their reward immediately after they complete the target behavior. This helps to strengthen the mental association between the desired action and the reinforcement.
7. Establishing the duration of the intervention. The ultimate aim of contingency management is for the individual to desire sobriety even when the therapist is no longer giving them rewards. This takes varying lengths of time. In any case, the end of the reward system is accompanied by relapse prevention strategies to help the individual remain sober.
How Contingency Management Is Used in Substance Use Treatment
In many ways, substance use is rewarding for individuals. It’s influenced by biological, environmental, and social factors. The excitement surrounding the drinking or using drugs as well as the mind-altering experience tends to outweigh all other considerations. That’s why people who are addicted to substances still feel a desire to use them even when they face negative consequences.
People who are addicted to drugs or alcohol can only recover if they choose to stop using substances. However, sobriety often doesn’t seem particularly rewarding in the early stages of recovery.
Individuals are often struggling with a wide variety of issues including broken relationships, debt, and poor mental and physical health. There’s also the temptation of cravings.
By entering a contingency management program, individuals get tangible rewards when they practice desirable behaviors. If they attend treatment consistently, stay away from drugs or alcohol, and otherwise adhere to the requirements of the program, the more likely it is that they will be rewarded.
There’s evidence for contingency management to be used in the treatment of several substance use disorders including those relating to:
A Word on The Use of Punishment
Punishment can be effective in reducing unwanted behaviors. However, CM programs tend to use it sparingly because:
- It damages the relationship between the patient and person administering the punishment
- Punishment is linked to a lack of engagement and consistent in the treatment and recovery process
- Punishment and the fear of punishment can make patients secretive and this has a negative impact on recovery
Types of CM Systems
There are many types of contingency reinforcement approaches in the substance abuse treatment community. However, rewards tend to be either voucher-based reinforcement or prize incentive programs. Voucher-based systems often pair breath testing or urine testing and reinforcement.
Every time a participant passes a drug test, they receive a voucher with an assigned monetary value. These vouchers can be exchanged for movie tickets, food vouchers, or other items.
The value of the vouchers is low in the beginning and it increases with consecutive positive behaviors. Prize incentive programs are based on similar principles but individuals get the chance to win prizes instead of receiving vouchers.
In addition to rewards for abstinence, individuals may also receive reinforcements for taking medication as prescribed, attending counseling sessions, or completing other agreed-upon activities.
CM for Adolescents
Contingency management can be just as beneficial for adolescents as it is for adults. If your teen is struggling with substance abuse, therapists may recommend CM. In some cases, it is preferred over cognitive-behavioral therapy or motivational enhancement therapy. When adolescents are involved, their parents are usually trained in the theory behind CM interventions and how they are delivered. That way, they can then work to help reinforce abstinence at home.
Build a Foundation for Recovery Through Contingency Management
If you are struggling to control your use of alcohol, prescription drugs, illegal substances, the high-trained professionals at The Discovery House in Southern California can help. We are a Joint Commission-accredited addiction treatment center that’s the premier facility in Los Angeles. We treat individuals from across the country but we’re ideally located to serve Westlake, Ventura, Woodland Hills, Thousand Oaks, and Santa Monica.
We treat the mind, body, and spirit through the use of contingency management and other evidence-based therapies. Each individual benefits from a customized treatment plan that takes their needs, goals, and unique challenges into consideration.
Furthermore, the Discovery House maintains a three-to-one client-to-counselor ratio so every individual gets the professional care they need. We offer a full continuum of care that includes detox, residential treatment, counseling, and aftercare planning. Contact us today to learn more about what we have to offer and determine if we’re the right treatment facility for you.