As an informative piece published by Psychiatric Times discusses, Contingency Management (CM) is a therapy approach that aims to help a person decrease drug-related behaviors. CM can also be applied to areas outside of drug treatment. It was first developed in the 1960s and based on the work of B.F. Skinner. Stated most simply, Contingency Management involves a trained therapist using reinforcement-based strategies to help individuals during the drug recovery process.
Contingency Management is usually used in conjunction with a substantive therapy approach, such as Cognitive Behavioral Therapy. The central tenet of the CM approach is that a person is likely to repeat positive behaviors if those behaviors are rewarded. The reward, in short, reinforces the healthy behavior. CM is considered an evidence-based therapy for substance abuse recovery because research shows that it can help recovering individuals to increase abstinence, remain in rehab, improve participation in rehab, and enhance the overall experience of being in rehab.
The National Institute on Drug Abuse describes the prize incentive approach, which falls under the umbrella of CM. Programs that use prize incentives may structure them differently, but overall, the recovering person sets a goal and then checks in with a rehab specialist to demonstrate the goal has been met. Typically, the program lasts at least three months and visits occur one or two times each week (and can be part of an inpatient or outpatient program).
One scenario is that a client has the goal of maintaining abstinence and provides a urine sample to a counselor during a visit. When a client tests negative for drugs, the counselor may hold out a jar or other receptacle that has tickets inside. The client can draw a ticket. The number of tickets that can be drawn varies, based on the number of weeks or visits that show a negative drug test result, for instance. The value of the prizes can range according to the program’s budget or policy guidelines (a range of value from $1 to $100 appears to be acceptable). Prizes can include any number of healthy lifestyle items, such as toiletries, household goods, electronics, clothing, sportswear, movie certificates, and restaurant vouchers. For more insight into how CM can work, here is a video illustration of a CM visit.
One argument that has been leveled against the prize incentive approach is that it promotes gambling, which is an addictive disorder (i.e., a process disorder). However, research shows that CM does not promote gambling.
Why Positive Reinforcement Can Be Effective
As the National Addictions Technology Transfer Center notes, research shows that while punishment (the opposite of CM) can at times be effective, in general, it is not very helpful in the context of addiction treatment. Whereas punishment aims to decrease behavior, Contingency Management seeks to promote behavior (e.g., abstinence and a lifestyle supportive of abstinence). Punishment, like the confrontation method, can cause such an uncomfortable environment that clients may drop out of their recovery program. It can lower the entire mood of recovery, including the attitudes among addiction service providers. Further, individuals in recovery may have extensive experience with being punished and feeling pain. In fact, trauma associated with punishment or emotional pain may itself have been a contributing factor in the person’s development of an addiction.
Contingency Management has the same goal, but it seeks to reach this end by reducing the relative value of the contingencies that support drug use through increasing the incentives that support abstinence. As abstinence grows in attractiveness, drug-using behavior should diminish in desirability. A number of writers have emphasized the importance of making treatment attractive and reinforcing (Bickel et al., 1998; Marlatt & Kilmer, 1998). This may be particularly important if, as Greaves (1974) has argued, addicted people frequently have disturbances in their ability to feel and experience pleasure. For many, it may be a deficit in pleasure, not hedonism, that is the force that drives addictive behavior. Certainly, patients seem to respond when a general culture of affirmation and support is integrated into a program that uses incentives (Kellogg et al., 2005).
In fact, trauma associated with punishment or emotional pain may itself have been a contributing factor in the person’s development of an addiction.
A paper written for the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration entitled Promoting Awareness of Motivational Incentives (PAMI) explains one important reason why Contingency Management can be especially helpful to individuals in drug recovery. Drugs target the brain’s reward system, so as abuse continues, the regulation of key neurotransmitters, such as dopamine (which induces euphoria) become dysregulated. One side effect can be that a person in recovery is not able to experience the natural state of pleasure that existed before the drug abuse. Providing incentives to recovering individuals may be a way to safely and naturally stimulate the brain’s reward system. In short, providing incentives may help a person to naturally strengthen and repair any damage to the brain’s reward system and dopamine operations.
While there are numerous benefits associated with Contingency Management, one is particularly worth highlighting. A person who is struggling with addiction may be getting negative feedback about the addiction from family, friends, schoolmates, work colleagues, and other stakeholders. Providing incentives in the recovery process can be seen as a way of continually giving attention and positive feedback to a recovering person. Again, this process builds on itself. The more time a person is abstinent, for instance, a greater number of incentives may be provided. This process can, therefore, help to build up a person’s self-esteem and confidence about the recovery experience. It can help to counteract negative feedback received in the past, feedback which has likely led to feelings of poor self-worth, shame, and self-blame.
As noted, Contingency Management can be used in combination with therapies that address the complex biological, psychological, and behavioral factors that underlie addiction. At the beginning of treatment, CM strategies may help a person to overcome apathy or resistance to the recovery process. A main benefit of rehab services is that they give the recovering person time to transition to a drug-free body and mind. Using CM is one way to help recovering individuals identify and meet immediate goals. This approach may be more comfortable than looking at the entire recovery process. Contingency Management is only one example of evidence-based methods that effectively support the recovery process.