Contingency Management (CM)

Contingency Management is often called motivational incentives, the prize method, or the carrot and stick method.

The Contingency Management (CM) approach, sometimes also referred to as “motivational incentives,” is based on the principle of operant conditioning – that behavior is shaped by its consequences. It is comprised of a broad group of behavioral interventions that provide or withhold rewards and negative consequences quickly in response to at least one measurable behavior (e.g., substance use as measured by a drug test, also called a toxicology screen).

WHAT HAPPENS IN CONTINGENCY MANAGEMENT?

In Contingency Management (CM) interventions, patients receive a reward for meeting a treatment goal or, in some cases, a negative consequence if the individual is unable to meet this goal. In the most common type of CM, patients receive cash, a voucher, or another prize in response to a negative urine toxicology screen (i.e., a good outcome).

Many of these prize reinforcement Contingency Management (CM) strategies have built-in bonuses, such that with the accumulation of negative toxicology screens over time, the patient can earn greater and greater rewards for each subsequent negative screen that is completed.

Contingency Management (CM) does not need to be implemented by a clinician per se. Parents of teenagers with substance use disorder or related problems might tie rewards (e.g., use the family car on Friday night) with a negative toxicology screen or other healthy measurable behaviors. Entire systems – rather than specific treatment programs – may also use CM to help individuals reduce or quit substance use.

Some states, for example, have used CM to reduce recidivism for individuals with alcohol-related criminal justice offenses (e.g., the 24/7 Sobriety program for repeat DUI offenders in South Dakota). In these cases, rather than sending the person to jail for a length of time, the individual is allowed to live at home but is required to remain abstinent from alcohol. They are monitored for alcohol use through daily breathalyzer tests or continuous alcohol skin sensor monitoring. If the individual tests positive — indicating that they had consumed alcohol— he/she receives a “swift, certain, but moderate” consequence, often 1 to 2 nights in jail (instead of 6 months in jail) depending on the contract.

Contingency Management (CM) may be used to increase engagement with other types of interventions, such as psychosocial treatment or medications.

WHAT IS THE THEORY BEHIND CONTINGENCY MANAGEMENT?

The overarching goal of CM is to consistently act in effective ways (i.e., to become empowered by values and personal goals) even when experiencing difficult or disruptive inner experiences.

Central Assumptions of Contingency Management:

Based on operant conditioning, a behavioral approach to learning first described by B.F. Skinner (which itself was based on the work of pioneering behaviorist John Watson). Operant conditioning theorizes that behaviors are shaped by their consequences; they will increase over time if followed by a pleasant experience (reward) or decrease if followed by an unpleasant experience (punishment).
Addiction is maintained and reinforced by a combination of the rewarding biochemical effects of the substance and environmental influences.
Targeted behavioral change can be achieved through the systematic application of immediate, and certain, rewards and consequences.
Individuals will be able to initiate and sustain abstinence (or reductions in substance use) as long as the rewards of abstinence are greater than the neurobiologically-mediated rewarding effects of substance use. They will also be able to initiate and sustain abstinence as long as the consequences of substance use are greater than any perceived consequences of abstinence.

WHAT ARE THE ORIGINS OF CONTINGENCY MANAGEMENT?

Researchers began studying Contingency Management (CM) as an intervention for alcohol use disorder in the 1960s. Also during this time, other more involved treatment approaches capitalized on these operant conditioning principles present in CM, while also incorporating ways to enhance coping skills and sober social activities, such as the Community Reinforcement Approach (CRA).

In the 1990s, dozens of studies showed Contingency Management is a helpful intervention for increasing abstinence among individuals with cocaine use disorder. Several empirical questions linger, however, about how long CM needs to be delivered before the abstinence-related benefits it offers will carry on without the rewards (or negative consequences) in place. Also, despite its place as one of the most effective approaches to address substance use disorder, few programs implement standalone CM given its mismatch with the fee-for-service model used in many managed health care settings (e.g., they can’t obtain the funds to implement it).

Some programs object to implementing CM on the grounds that it could be classified as “a game of chance.” In some CM interventions, for example, participants pick tickets out of a fishbowl after a negative toxicology screen, but only some of the tickets have prizes, and these prizes range in value. That said, there is currently no evidence that CM increases gambling behavior. Others object on philosophical grounds – that individuals should not be paid money to abstain.

EVIDENCE FOR CONTINGENCY MANAGEMENT

Despite these concerns by some clinical program staff, the benefits of Contingency Management (CM) for engaging people in treatment and increasing abstinence rates during treatment are strong. Prize reinforcement CM is one of the most effective treatment approaches directly addressing substance use disorder. CM also has strong empirical support as an conjunctive intervention to increase psychosocial treatment and medication adherence.

Regarding Sobriety 24/7, an example of system-wide CM approaches described above, the clarity and transparency of the contract and the immediacy and certainty of the consequence, even though a modest one, makes this approach a highly beneficial and cost-effective one for multiple DUI offenders.

CM FOR ADOLESCENTS

Like adults, Contingency Management (CM) promotes benefit in adolescents as well. Importantly, this CM benefit may be provided over and above the empirically supported combination of Motivational Enhancement Therapy and Cognitive Behavioral Therapy (MET/CBT). Unique to adolescent CM approaches is that parents are typically trained in the rationale and delivery of CM interventions. Parents efforts to reinforce abstinence can be in addition to rewards received for negative toxicology screens by the treatment program.

CITATIONS

Kilmer, B., Nicosia, N., Heaton, P., & Midgette, G. (2013). Efficacy of frequent monitoring with swift, certain, and modest sanctions for violations: Insights from South Dakota’s 24/7 Sobriety project. American Journal of Public Health, 103(1), e37-e43. doi: 10.2105/AJPH.2012.300989
Petry, N. M., Martin, B., & Simcic, F., Jr. (2005). Prize reinforcement contingency management for cocaine dependence: integration with group therapy in a methadone clinic. Journal of Consulting and Clinical Psychology, 73(2), 354-359. doi: 10.1037/0022-006x.73.2.354
Petry, N. M. (2006). Contingency management treatments. The British Journal of Psychiatry, 189(2), 97-98. doi: 10.1192/bjp.bp.106.022293
Stanger, C., Budney, A. J., Kamon, J. L., & Thostensen, J. (2009). A randomized trial of contingency management for adolescent marijuana abuse and dependence. Drug and Alcohol Dependence, 105(3), 240–247. doi: 10.1016/j.drugalcdep.2009.07.009