Rehab 4 Addiction

Contingency management is a form of behavioural therapy. It aims to change people’s habits by reinforcing positive behaviours. It does so through the use of incentives. Positive behaviours can include sobriety or abstinence from drugs. They can also include continuing with a programme of treatment.

In other words, contingency management is ‘the systematic reinforcement of desired behaviours and the withholding of reinforcement or punishment of undesired behaviours’. [1]

What is the nature of the positive reinforcement which CM provides? Normally it comes in the form of prizes. These prizes can include vouchers, coupons and privileges.

For instance, a common goal for patients at a CM clinic would be to stay clean. To provide evidence of this, patients would need to produce drug-free urine. In exchange, they would receive prizes such as coupons to be exchanged at a supermarket.

Contingency management (CM) is often used in combination with other treatments. For instance, it might be paired with cognitive therapy like CBT (Cognitive Behavioural Therapy).

What are the differences between contingency management and other forms of treatment?

The main difference between CM and other forms of treatment is that CM is based on goals and incentives. In fact, it bears little similarity to conventional forms of therapy.

It does not address underlying causes for addiction. This sort of work needs to be done in a CBT session. For this reason, CM often goes well with CBT.

CM is actually quite unique in its approach. This can be a strength. Patients who have struggled with other forms of treatment may find that CM is exactly what they needed.

History and theory of contingency management

Contingency management is rooted in something called operant conditioning. Operant conditioning is the belief that you can teach someone through the use of rewards and punishments. This, in turn, comes from behaviourism.

Behaviourism is a form of psychology that grew popular in the 1900s. It also places stress on the role of reward and punishment in shaping behaviour.

To give an example of this, when you touch something hot, it causes you to feel pain. Over time, this experience trains you not to touch hot things.

Operant conditioning and CM have filtered into many parts of society. You can see them in action in schools and prisons, where good and bad behaviour are rewarded or punished accordingly.

Principles of contingency management

Below, we outline six principles of contingency management:

  • Behaviour to target: The first step in any contingency management programme is to work out what behaviour it is you want to encourage or discourage. This might be a positive behaviour such as staying abstinent from drugs or alcohol or turning up to treatment sessions. Or it could be a negative behaviour such as buying or using drugs.
  • Choosing a client to participate: Contingency management will not suit every client. Those who are well-motivated and have been in treatment for a long time probably won’t benefit massively from this form of treatment. By contrast, someone who lacks intrinsic motivation and has only recently got clean would be the ideal candidate for this form of behavioural therapy
  • Selecting a reinforcer: It is crucial that the client has a prize to look forward to. If they have no desire for the reward they are being offered, then there will be little motivation for them to work towards their goals. On the other hand, certain rewards can be dangerous, such as money, which could lead to a relapse. Rewards need to achievable, not too valuable, and yet still something to be desired. This can be a difficult balance to strike but it is essential for CM to have the best effects
  • Value of incentive: As well as choosing the right kind of incentive, it is also important to choose the right value or magnitude of incentive. This has to be affordable for the clinic, but still rewarding. It also has to take account of the magnitude of the goal that the client has achieved. For example, a client who has been clean for 12 months ought to get a more sizeable reward than a client who has only been clean for a week. The size of the incentive also needs to be balanced with factors such as how the patient responded to previous rewards. E.g. if the patient relapsed after getting a valuable reward in the past, it might not be sensible to give them another valuable reward unless you are sure it won’t endanger their recovery
  • How often to give out rewards: Some clinics give out rewards very frequently. Others less so. It may be wise to deal with the frequency of rewards on a case-by-case basis
  • Timing: It is important to get the timing of the reward right. Ideally, the reward should be given out just after the positive/negative action. This helps to reinforce the goodness or badness of the action

When should the intervention end? The aim of CM is that motivation to stay sober continues after the end of treatment. For some, CM will need to last for a long time. For others, it may be shorter. It depends entirely on the individual.

That being said, every patient needs to have coping strategies in place for when they finish CM. Taking away a powerful incentive for staying sober can be risky unless the patient is ready to do so.

Positive vs negative reinforcement

In contingency management programmes, the emphasis is on positive reinforcement. There may, at times, be negative reinforcement, but this can simply be the lack of a reward.

Contingency management is therefore very non-confrontational. In this respect it differs from other forms of treatment. The reason for this is that patients tend to respond well to positive reinforcement. It validates their attempts at sobriety and contributes to their sense of self-worth.

Types of contingency management programmes

At the beginning of treatment, the patient will agree on a set of goals. They may then sign a contract in order to agree to the programme. This helps to hold them to account if they decide to relapse.

Two of the most common forms of contingency management programmes include coupon-based programmes and prize-based programmes.

1. Voucher-based programmes

During voucher-based contingency management programmes, vouchers are awarded to patients who provide drug-free urine samples.

These vouchers can be exchanged for goods and services, such as food, clothing, electronics and so on. The more negative tests that a person submits, the higher the value of the vouchers they obtain.

One meta-analysis looked at voucher-based reinforcement therapy (VBRT) studies. It found that VBRT ‘generated significantly better outcomes than did control treatments’ [2]. Also, interestingly, it found that ‘more immediate voucher delivery and greater monetary value of the voucher were associated with larger effect sizes.’

This ties in with the idea that the sooner a reward is given out after a positive action, the more effective it is. It also suggests that more valuable rewards are more effective.

This makes sense although of course not all clinics have the resources to give out highly valuable prizes on a regular basis.

2. Prize-based programmes

During these programmes, a person who submits a drug-free urine sample enters a prize draw. The prizes are often cash-based. The person has a chance to win a big prize, a small prize, or a note with a few words of encouragement.

Research has shown that prize-based programmes can also be effective. One study looked at a group of patients, some of whom had been assigned to normal care, and others who were receiving normal care and a prize-based contingency management programme.

It found that those with the added CM component submitted more drug-free urine samples and stayed in care for longer. [3]

Criticisms of contingency management

Below, we’ve listed some common criticisms of CM and some responses.

Contingency management is a form of ‘bribery’ and is ‘unethical’. People sometimes find the idea of giving patients money for staying sober uncomfortable.

However, when people are awarded prizes in other contexts, there is no outcry. For example, cash incentives are often offered to people in order to encourage them to complete surveys.

Similarly, reinforcers are often used for people with autism to reward positive behaviours. [4] It seems, therefore, that there is something specific about giving money to those with substance use disorders (SUDs) that people find unpalatable.

This may be more of an emotional reaction than the product of any genuine moral grievance.

Another criticism that is often levelled at CM is that when the programme is complete, drug use will return to normal. Some studies have lent credence to this view. [5] However, many others have shown that CM can promote long-lasting abstinence. [6] What’s more, the same criticism could be applied to many other treatment programmes and therapies.

A third criticism is that CM may reduce internal motivations for change since it relies entirely on external motivations like vouchers and prizes. This does not seem to be the case. This study, for instance, found that CM improved treatment outcomes and had no impact on motivation. [7]

A fourth, and final criticism of CM is based on practical considerations. CM is costly since it costs money to pay for prizes and vouchers. It also costs money to pay for staff to supervise the collection of urine samples. This can make if more difficult to implement CM in a practical setting. [8] This is a valid criticism, and maybe one reason why CM is less common in the UK than is in the US. [9]

Final thoughts

Contingency management is a highly effective form of treatment for addiction. Although it has faced some criticism, and remains unpopular in the UK, it is actually supported by a wealth of evidence. Indeed, it is ‘one of only two psychosocial interventions […] recommended by NICE because of the strength of evidence for its effectiveness.’ [10]

Contingency management should be recommended for those who are at an early stage of their recovery. It might also be effective for those who have had limited success with other forms of treatment. Due to its uniqueness, it is clearly worth trying for anyone in the grip of a substance use disorder.