What Is Contingency Management and How Does It Support Sobriety?

Contingency Management, sometimes abbreviated CM, is a type of behavioral therapy which is highly effective as part of outpatient addiction treatment. CM is founded on operant conditioning, the psychological approach of shaping behavior by positive reinforcement.

A simpler way of describing this method of using motivational incentives as part of intensive outpatient therapy is as the reward, prize, or carrot-and-stick approach to changing addictive behavior. This therapy has been proven to help people overcome substance use disorders and other mental health conditions.¹ CM is even effective at enhancing weight loss, increasing exercise levels, and improving compliance with medication schedules.

What are the origins of this behavioral therapy, how effective is it, and how is it used to help addicted individuals succeed in recovery?

The History of Contingency Management Interventions

In the 1960s, the theory of contingency management was first applied to alcohol abuse treatment in conjunction with other operant conditioning methods. Some programs involved both positive rewards and negative consequences, depending on whether the individual remained sober.

Over time, the positive rewards proved more effective than punishments at encouraging long-term sobriety. As the results of this approach were so promising, CM was used for other substance use disorders in the 1990s, proving helpful for increasing abstinence from cocaine and other addictive substances.²

How Does Contingency Management Treat Addiction?

By reinforcing the desired behavior—in this case, abstaining from substance use—this approach is founded on basic principles of behavioral therapy, including:

• The understanding that when desired behaviors are reinforced (rewarded) soon after they occur, those behaviors are likely to be repeated.
• Working with the individual to demonstrate that measurable success at achieving the desired behavior will be consistently rewarded.
• The size or perceived value of the reward should rise as a result of maintaining the desired behavior for increasingly longer periods of time.

So, for someone struggling to achieve sobriety, measurable success is often a clean drug test. Each negative result will be reinforced with a reward, the value of which increases as each consecutive test is clean. Rather than focusing on past mistakes and willpower alone, contingency management makes staying sober a rewarding experience.

How Effective Is Contingency Management?

Contingency management is effective for most people in a wide variety of situations. Of an analysis performed of all psychosocial treatments for addiction, CM was found to have the greatest measurable impact.¹

There are more studies and statistics on the subject than can be listed here, but some of the key points that support CM as an effective part of inpatient or outpatient drug rehab include:

• Increasing retention in treatment by at least 14%.¹
• Making individuals four times more likely to maintain sobriety for at least 12 weeks.¹
• Shown to be a cost-effective solution in stopping repeat DUI offenses.²
• Known to be successful at changing a wide range of addictive behaviors, including the use of opioids, cocaine, alcohol, marijuana, stimulants, and cigarettes.¹

Why Isn’t CM Used More Widely in Addiction Treatment?

As effective as contingency management can be in the recovery process, this method is not often seen in most outpatient addiction treatment programs. Some of the reasons reported are:

• Many mental health providers surveyed indicated that they were not familiar with contingency management, often through lack of formal training or coursework on the topic.
• Of those that were aware of the potential of the therapy, many found that it did not fit with the standard fee-for-service model used in managed health care.
• Some organizations object to the perception that this approach “pays” addicts to stay sober or encourages gambling.

While there are certainly reasons to consider the viability of a particular type of therapy in each individual treatment environment, most of these obstacles can be overcome by treatment facilities that wish to take advantage of this highly effective way of reinforcing positive choices.

Contingency Management Benefits Those with Co-Occurring Conditions

Many times those who struggle with addiction also have mental health challenges. When these conditions are intertwined, they are called co-occurring or dual diagnosis. Contingency management offers a solution which helps stop the habit of dangerous self-medication.

Studies show that CM helped reduce cocaine and marijuana abuse in those who also had a psychotic disorder.¹ It is also a recommended treatment for the high rates of cigarette smoking among those with schizophrenia. This therapy is widely used in behavior shaping for children and adults with autism or other cognitive difficulties and in helping teenagers reduce problem behaviors.

CM is also beneficial to those with difficulty adhering to a required medication schedule. These might be anti-psychotics, mood stabilizers, or medications which work to prevent relapse by removing the ability of drugs or alcohol to produce pleasant effects or by actively making their effects unpleasant.

Examples of Contingency Management Programs for Addiction

Here are some ways that positive reinforcement is being used to improve inpatient and outpatient addiction treatment programs:

• Rewards for meeting treatment goals, in the form of cash, a voucher for a prize drawing, or another valued incentive for a weekly (or even daily) drug screen.
• Programs may incorporate negative consequences for not abstaining, such as loss of privileges, which may include driving, attending social events, or leaving an inpatient facility.
• Incentives in the form of built-in bonuses, so that rewards become greater with each successive clean drug test. For example, an individual might receive an extra chance in a prize drawing for each consecutive week of sobriety.
• Some states have incorporated contingency management into their criminal justice sentencing, reducing repeat DUI offenses as part of alcohol detox treatment and ongoing monitoring for sobriety. Passing a required daily Breathalyzer allows offenders to enjoy relative freedom, while failing to pass may result in one to two nights in jail.

What Are the Indicators of Effective Contingency Management?

This form of behavioral therapy must follow the principles of operant conditioning theory to achieve the greatest impact. It is not enough to simply offer rewards for good behavior. The program protocol should include these key factors:

• Clearly identifies the behavior(s) to be targeted. This might be an undesirable behavior to be reduced, or a desirable behavior to be increased, or both. Examples include passing or failing a drug test, engaging in appropriate social interactions, meeting attendance, or completing other program requirements.
• Engages individuals on a voluntary basis. Not every person in recovery needs or wants this type of therapy. For a successful program based on motivation rather than punishment, ideally participation should be optional. However, this treatment is strongly recommended for those who have failed to remain sober or who have a history of relapse.
• Offers a desirable and appropriate reward. To be effective, the reward must reinforce the desired behavior. This means it must be of value to the individual being rewarded. Money may not be the best choice in cases where it might be misused. Therapists should ensure that the rewards offered are desirable and realistic for participants.
• Increases the size or value of incentives over time. While small prizes or cash rewards are useful in the early stages, in order to continue to reinforce greater achievements, the reinforcement must become more valuable as well, often shifting to activities or privileges rather than monetary-based prizes.
• Measures and reinforces results frequently. The reinforcement should happen as soon as possible after the target behavior is performed. Extended time between the action and the reward (or negative consequence) diminishes the effectiveness of the therapy.
• Recognizes the solid psychological basis behind operant conditioning. Consistent therapy of sufficient duration is needed to build new habits and link sobriety with a positive brain and body response. These connections take time to become firmly established.
• Transitions smoothly past the need for outside reinforcement. How long a CM program should continue varies widely based on individual needs. However, over time, this therapy “trains the brain” to feel good about feeling sober. When the person is ready to support their own sobriety and has a relapse prevention strategy in place, they should “graduate” from this type of program.

Commitment to Positive Change Is Self-Rewarding

Some behaviors are said to be self-reinforcing, or self-rewarding, because they are inherently pleasant. Very often, drug or alcohol abuse develops from this learned response. An association between using and the “reward” of intoxication was built by the very same method that Contingency Management uses to reverse that response.

By incorporating CM into our outpatient addiction treatment, RECO Intensive brings this cutting-edge therapy to the table for you and those you care about. Of all the rehabs in Florida, choose the one that offers the broadest range of therapies while focusing on the wellbeing and full healing of their clients. Contact us today to experience the true rewards of positive personal change with our empowering treatment programs.

Sources:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083448
2. https://www.recoveryanswers.org/resource/contingency-management