Contingency Management: Proven Methods

What is Contingency Management?

Contingency management (CM), or motivational incentives, refers to a form of behavioral therapy used to correct negative behaviors or habits by offering rewards for positive behaviors. It is occasionally also referred to as the prize method, or the carrot and stick method.

This behavioral approach is based on the principles of operant conditioning and can be used as a stand-alone treatment or alongside other forms of treatment.

When used in addiction treatment, individuals are rewarded for actions taken towards recovery; for example, a drug-free urine sample would merit some sort of positive reinforcement as a means of encouraging repetition of this action in the future

In some cases, disciplinary measures or restrictions of an individual’s privileges may occur in response to their engaging in negative behaviors or activities. However, this is not usually practiced when treating addiction, in order to prevent possibly triggering regression into substance usage.

Who Can Benefit from Contingency Management?

Contingency management has been found to be effective in treating several types of issues, including substance use disorders, impulsive behaviors, and other mental health conditions.

In some cases, this form of therapy has also been found to be effective in correcting behavioral issues in children. It may also be beneficial for individuals who are struggling with a dual diagnosis of co-occurring mental health or other disorder alongside a substance use disorder.

How Does Contingency Management Work?

Addiction is a very personal disease, and each individual struggling with substance abuse will likely need a personalized approach to getting clean. Individuals participating in contingency management therapy will first need to communicate with their medical provider to determine the best path to sobriety for them.

Once this has been established, one of two contingency management approaches will be taken: voucher-based reinforcement treatment, or prize incentive-based treatment. In some cases, a written contract between the client and their treatment provider may be produced in order to keep each party in alignment with the client’s care goals.

Voucher Based Reinforcement

Voucher-based reinforcement therapy produces positive reinforcement by using a voucher system. This method rewards a client for desired behaviors, such as providing consistently drug-free urine samples.

These vouchers can then be exchanged for monetary items or services that reinforce this sober lifestyle, typically increasing in value as treatment progresses. These goods and services can range from clothing and food supplies to movie tickets or other forms of entertainment.

Typically, the longer an individual successfully avoids substance use, the greater the reward they will receive.

According to The National Institute on Drug Abuse, this form of contingency management has been found to be particularly effective for individuals with an opioid use disorder, and cocaine-using methadone patients.

Prize Incentive

The prize incentive method works similarly to the voucher system but involves physical cash prizes rather than trade-ins. In this approach, clients receive rewards based on positive behavior, such as providing urine samples that are substance-free or passing a breathalyzer test.

Contingent prizes versus vouchers will typically involve clients choosing a slip of paper at random from a bowl, which will have a reward written on it. These can simply be words of encouragement, or a monetary prize ranging from $1-$100. The value and frequency of this reward ‘pulls’ will usually increase as a client stays consistent and clean in their treatment attendance.

While some concerns have been raised that this method might produce gambling habits, research has yet to provide any empirical evidence supporting this fear.

Can I Get Paid for Being Clean and Sober?

While contingency management treatment does offer financial incentives for continuous abstinence, the effectiveness of this treatment is significantly linked to the value of the reward being offered. Thus, the less significant the prize (cash or otherwise), the less effective CM treatments are likely to be.

Furthermore, there are several state and federal laws that limit the amount of money an individual can receive during their substance abuse treatment process. There are several reasons for this, including:

• Fears that these prize funds will be used in funding an individual’s drug/alcohol abuse.
• The belief that individuals should not be rewarded for overcoming substance addiction.
• Attempts to limit healthcare providers from enforcing a specific treatment option and/or insurance plan on their patients.

So, while it is possible to get paid for being clean and sober, the level of financial compensation an individual can receive will likely be relatively small due to these current legal restrictions.

Is Contingency Management Evidence-Based?

Contingency management is based on basic behavioral analysis research and uses operant conditioning principles that are applied in various different areas of life. Thus, a vast amount of empirical evidence has been produced supporting the effectiveness of CM treatments in managing addiction, a large majority of which was provided by methadone clinics.

Furthermore, research done around contingency management has predominantly found that not only is it effective in treating addiction, but in boosting both patient and provider morale in producing and engaging with recovery incentives.

What are the 7 Principles of Effective Contingency Management?

The contingency management approach is set on a foundation of seven principles that determine the effectiveness of this treatment. These principles are:

• Target Behavior
• Target Population
• Type of Reinforcer (Incentive)
• Magnitude (or Amount) of Reinforcer
• Frequency of Reinforcement Distribution
• Timing of Reinforcement Distribution
• Duration of Reinforcement(s)

Target Behavior

When it comes to behavioral treatment, choosing a specific behavior to focus on can be a tricky process. However, this is one of the most important factors in setting up a behavioral contract between clients and their treatment providers.

There are several determinants that can be focused on when choosing a specific behavior to treat, including:

• How problematic the behavior is for the client.
• Consistency of a behavior with a client’s treatment plan.
• The ability of the patient and their treatment provider to observe and describe the behavior.
• The ability of the client to change behavior; how achievable is this change, and what level of motivational incentives/rewards are appropriate for it?

When using contingency management as addiction treatment, the target behavior will typically be the individual’s alcohol/drug abuse. However, for clients dealing with co-occurring mental health conditions, negative thoughts and behavior associated with this may be addressed in addition to or as the main behavior causing their addiction.

Target Population

When it comes to addiction, this form of treatment will usually be used on an individual basis, in which rewards will be determined based on how effective they are considered to be in regard to a specific person.

However, in some cases of substance use, certain groups of individuals, or sub-populations, may be targeted. An example of this can be seen in the forms of methadone maintenance treatment for individuals with a dual diagnosis, in which contingency management is used in a group setting.

In these cases of multiple individuals being targeted at once, contingency management works best when used alongside other forms of therapy and treatment. For example, these methods can be integrated into both inpatient and outpatient behavioral treatment programs, or as an additional aspect of certain psychiatric treatments.

Type of Reinforcer

Choosing a reward or reinforcement method can play a large role in determining the effectiveness of this approach. In order to determine a reward system that will provide the best chance for success, treatment providers will likely ask their patients what prizes they prefer.

These incentives can range from being monetary to existing in the form of access to services, employment opportunities, or social benefits.

Magnitude of Reinforcer

In order for a reward system approach to addiction treatment to be successful, the type and magnitude of the reinforcement being distributed must be able to compete with the reward an individual would receive from their substance use.

This is when treatment becomes far more personalized, as the reward level necessary will vary drastically depending on a person’s level, history, and type of substance use. For example, individuals using multiple different substances or at much higher levels than others will likely need a greater reward incentive to achieve successful behavior modification.

Frequency of Reinforcement Distribution

How often a reward is distributed in response to the desired behavior can have a large impact on an individual’s treatment goals.

In order to receive adequate motivation to avoid drug/alcohol cravings, frequent and consistent reinforcement distribution for continuous alcohol and/or drug abstinence is vital to the success of an individual’s CM treatment.

An individual’s distribution schedule can vary based on a number of factors, including the behavior being targeted, their access to clinical settings in which to receive treatment, and their individualized plan to overcome substance abuse.

Timing of Reinforcement Distribution

Operant conditioning works on the idea that actions followed by reinforcement promote the repetition of these actions. Thus, the timing of a reward distribution in achieving the desired behavior of discontinued alcohol and/or drug use is extremely important.

When it comes to behavioral therapy, contingency management requires that goal behavior be rewarded as soon as possible in order for positive associations to be properly developed with it.

Duration of Reinforcement(s)

The duration of an individual’s contingency management process can follow two different styles, including:

• Fixed Duration: The duration of the treatment process is determined in advance, and consists of a fixed amount of time treating substance usage (typically around 3 months).
• Variable Duration: The duration of the treatment process is determined by a client’s progress throughout it, and how effective it appears to be for them.

Another factor that may determine the duration of this process may be financial. Depending on the level of funding available to certain treatment centers, cost-effectiveness can play a significant role not just in the length of treatment, but the value of the reward system available as well.

Are There Other Forms of Contingency Management?

Contingency Management exists in many forms outside of promoting drug abstinence, including:

• The Community Reinforcement Approach and Family Training (CRAFT) Model: This model focuses on the family members of individuals who are struggling with alcohol dependence, equipping them with skills and methods of helping their loved ones achieve sobriety in a positive and supportive manner.
• Token Economies: Token economy systems, which function through the use and exchange of specific symbols (or tokens) associated with having monetary value, have been successfully used in assisting individuals with substance use disorders, special needs, and delinquency issues.

Contingency Management and the Matrix Model of Stimulant Treatment

The Matrix Model of stimulant treatment was developed in 1980 as an additional way of treating substance use disorders. This model is often used in various different treatment programs in addressing stimulant dependencies (i.e., a methadone or cocaine use disorder).

Many individuals who have followed the founding principles of this model have found success in overcoming their substance use disorder. These principles include:

• Producing a strong relationship between a therapeutic counselor and their client.
• Teaching clients time management skills, as well as how to lead a healthy and organized lifestyle.
• Educating clients on how to recognize and manage acute and subacute withdrawal symptoms, as well as substance cravings.
• Providing opportunities for clients to learn and practice techniques that can help prevent relapse, as well as coping skills should this occur.
• Involving family and significant others in these processes to help them better support and avoid possibly hindering their loved one’s recovery process.
• Encouraging clients to participate in support groups, either within their community or online.
• Conducting random urinalysis and/or breath tests to assess treatment effectiveness and client progress.

In addition to being used as a form of addiction treatment, this model has also been used in various psychosocial treatments and has even helped reduce the possibility of HIV transmission through risky sexual behaviors for some individuals.

Is Contingency Management Like Gambling?

Gambling, by definition, involves an individual risking something of value in order to potentially gain something of greater profit. Contingency management, however, does not require this risk-and-reward factor; in fact, CM interventions reward behaviors that decrease an individual’s risk of engaging in activities that could result in negative consequences.

The Limitations of Contingency Management

There are currently several state and federal laws that limit the availability of contingency management treatment settings in the United States. One of the main reasons for this is that it can be considered unlawful for individuals participating in federally or state-funded healthcare programs to receive incentives for staying sober.

This is due to a fear that these rewards may be misused to further an individual’s substance use, particularly should they exceed an amount that is considered to be acceptable. Furthermore, there are those who believe that individuals should not be rewarded for engaging in “normal” behavior, such as avoiding drug and alcohol use.

Depending on where an individual is located, the limitations on their specific treatment program will vary based on state laws, as well as their health insurance provider and coverage plan.

Contingency Management as a Component of Addiction Treatment

When it comes to ensuring an individual’s best chances at achieving a drug-free lifestyle, this often requires that an inpatient and/or outpatient treatment approach incorporates contingency management methods.

Because incentives improve outcomes when it comes to overcoming addiction, using a reward-based approach to recovery in combination with other medical and/or therapeutic treatments only serves to further increase an individual’s chance of successful sobriety.

Contingency Management vs Harm Reduction

Harm reduction approaches (such as Moderation Management) are designed for non-dependent problematic substance users who seek to limit their intake of a substance (typically alcohol), rather than achieve complete abstinence from it.

While both approaches work to gradually reduce an individual’s substance use, contingency management does so with the goal of reaching total sobriety. Particularly for individuals struggling with some form of drug addiction, such as opioid use disorders or cocaine dependence, it is strongly recommended that they do not pursue a harm reduction approach.

Because these substances are so addictive and can be lethal (whether due to health problems that occur over time or accidental overdose), it is imperative that they seek immediate medical help in getting sober.

Sober Living and Aftercare Planning with Contingency Management

While Contingency Management has been found to be effective in treating addiction, like many treatment options, it only extends over a certain period of time. This duration is often indefinite and recent studies have suggested that it works better when based on individual needs.

However, having a plan on how to maintain sobriety and coping skills in place should a relapse occur is always recommended for individuals recovering from addiction. There are several steps that can be taken in maintaining a clean and sober lifestyle, including:

 

• Getting Therapy. Seeking out therapeutic or other counseling services can be a great way for individuals to address any underlying mental health issues or negative feelings that may be causing their substance usage, and learn healthy coping mechanisms for them.

 

• Joining Support Groups. Finding other people, whether in their community or online, who have also struggled with and recovered from addiction can help individuals feel less alone and more inspired in their own recovery journey.

 

• Asking for Help from Friends & Family. Sharing their concerns, triggers, and successes with trusted loved ones can help individuals stay on track with their sobriety. It may also help to have people who will hold them accountable should they start to slip back into old habits.

 

• Practicing Healthy Habits. Maintaining a balanced diet, getting plenty of rest, practicing mindfulness skills, staying hydrated, and incorporating exercise and basic self-care practices into their regular routine are all simple, but effective ways of keeping individuals happy, healthy, and sober.

Where Can I Find the Best Contingency Management Rehab?

Choosing to overcome an addiction and take back control of your life can be an incredibly scary decision. For some people, this may even feel impossible. But it doesn’t have to feel that way; here at Find Addiction Rehabs, our team of representatives is dedicated to supporting you in finding the best treatment programs and centers for your recovery goals.

Whether you or a loved one is looking to see if contingency management is right for you, or if you want to find other ways of getting sober, we are here to help you. You don’t have to take that first step alone; call us today at our 24/7 hotline, and we’ll help you get started on a path to a happier, healthier you!

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