Article at a Glance:

  • Contingency management is a highly effective treatment for substance use disorders.
  • The approach is based on the concept that it’s easier to change when new and healthy behaviors are linked to rewards.
  • Though widely researched and linked to positive outcomes, contingency management has been restricted by a lack of financial support from the federal government.
  • It may be particularly useful for methamphetamine and cocaine addiction, which lack alternatives for medication treatment.

What Is Contingency Management (CM) Therapy?

Contingency management is a behavioral treatment approach that is used in many addiction recovery centers.

This reward-based approach focuses on promoting positive behavior by using motivation as the driving force for change. It also offers reinforcement in the form of rewards when a person meets certain day-to-day recovery goals. Goals might include:

  • Attending treatment sessions
  • Having clean urine samples
  • Completing a treatment plan task, such as journaling or exercising
  • Taking psychiatric medication as prescribed

Rewards might be withheld if a patient doesn’t meet an expectation. However, what makes contingency management unique is the lack of emphasis on punishment. The concept is simple and intuitive: If a positive behavior is rewarded, it is more likely to be repeated in the future. On the flip side, when negative behavior is punished, it can lead to a sense of alienation and actually reduce a person’s motivation to change.

Contingency management has also been used in psychiatric care for mental health disorders to motivate people to stay in treatment. It has also been used effectively in weight loss and fitness programs.

Similar practices also occur in homes, schools and workplaces. For example, a parent may agree to bake cookies for their child if they finish the vegetables on their plate. A company might offer an employee bonus that’s tied to reaching certain quarterly goals.

FAQs

  • How does contingency management work in promoting abstinence from substances?

    Reward systems in our brain motivate us to pursue a sense of reward. Behaviors that are linked to rewards can become part of a positive feedback loop that reinforces those behaviors. However, substance use can also get tangled up in this reward system and develop into a serious disorder. Contingency management works by using that same positive feedback system; it motivates a person toward recovery by providing manufactured rewards for meeting day-to-day treatment goals.

  • Will individuals lose motivation once incentives are no longer offered?

    A potential downside of contingency management is that abstinence may not continue once incentives and other treatments are no longer offered. For this reason, some experts believe that contingency management should be a continuous treatment. Still, contingency management for stimulant, opioid or polysubstance addiction was found to be 22% more likely to lead to abstinence at six months post-treatment compared to other interventions.

  • Does contingency management work for treating co-occurring mental health disorders?

    Contingency management has been effectively used to treat addiction and co-occurring mental health disorders. It has also been shown to increase drug abstinence (or reduce use), improve quality of life and reduce the need for inpatient treatment.

  • What are some pros and cons to using contingency management therapy in addiction treatment?

    The immediate and powerful reinforcement of drug use compared to the physical and psychological challenges of early sobriety can make recovery hard to maintain. Contingency management works to solve this by providing immediate positive reinforcement for sober behaviors, which can help rewire the brain toward recovery.

    However, the treatment is not without controversy. Some critics have labeled it as unethical or like a bribe, and many public and private insurers don’t cover it. One concern is that financial incentives can lead to fraud and waste.

Different Types of Contingency Management in Addiction Treatment

In residential and outpatient rehab settings, contingency management programs can include incentives for clients to follow program rules and meet recovery goals. The type of incentive can include:

  • Vouchers
  • Prizes
  • Money
  • Gift cards
  • Extra privileges

Voucher-Based Reinforcement (VBR)

Voucher-based reinforcement (VBR) is a type of contingency management where patients receive vouchers as an incentive for having negative drug tests. These vouchers can be used in place of cash to purchase things like clothing, food and movie tickets. The voucher values start out low and increase with the number of consecutive drug-free samples. VBR has been effectively used in treatment programs for opioid and cocaine use.

Prize Incentives

Contingency management programs that use prize incentives can include prizes of various values to represent different milestones and promote recovery behavior. It can be done as a weekly prize drawing or through another form of selection.

Prize incentive programs are usually at least three months long, with drawings at least once per week for participants who complete goals or have negative drug tests. There has been a concern that prize incentives may promote gambling behavior, but this connection has not been found in research.

Paying People to Stop Using Drugs

The San Francisco AIDS Foundation developed a 12-week contingency management program that offers people with meth addiction a small amount of money three times a week in exchange for negative drug tests. The program has been a resounding success, with 63% of participants stopping their meth use completely and another 19% reducing their use. One participant noted that the drive to stay sober became less about the money and more about the positive interaction and feelings of self-worth he had when his urine samples were negative.

With California facing a public health crisis related to meth and cocaine use, state legislators have their eye on contingency management as a well-researched treatment option. A bipartisan bill currently under review by the governor will allow California to use federal funds for contingency programs like the one used by the San Francisco AIDS Foundation.

Is Contingency Management Effective?

Studies show that contingency management in addiction recovery can be effective in a variety of situations. A 2021 meta-analysis of 74 clinical trials on patients receiving opioid addiction treatment found that contingency management was associated with improved treatment attendance, medication use and abstinence.

Contingency management has also been shown to be an effective treatment for stimulant misuse. One study found that 49% of the contingency management group completed the entire course of treatment compared to 35% of the standard treatment group. Further, the number of people who remained sober from stimulants for the full treatment period was nearly four times greater in the contingency management group.

Building on the promising research, the Department of Veterans Affairs launched a contingency management program for patients with substance use disorder. After testing nearly 30,000 urine samples in the program, they found that more than 90% of the samples tested negative for the target substance.

With an intervention that so consistently produces positive results, some have asked whether the moral objection to contingency management holds water.

Contingency Management as Part of a Comprehensive Treatment Program

Addiction is a subtle and powerful disorder that often requires a multi-pronged approach, including:

  • Behavioral interventions, such as contingency management
  • Psychotherapy, such as cognitive behavioral therapy
  • Group therapy
  • Social supports
  • Medication-assisted treatment

The Recovery Village offers comprehensive addiction treatment programs that incorporate a wide variety of therapy options. If you or a loved one are struggling with a substance use disorder, help is available. Contact The Recovery Village today to learn how our individualized treatment programs can support you in finding recovery and living your life on your terms.

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