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Understanding Contingency Management Therapy

Doing drugs or drinking provides a reward to the person who uses and abuses them – the mind-altering experience or euphoria achieved. Contingency Management Therapy uses the concept of a person desiring a reward to create a unique approach to recovery. It gives a person a reason beyond repairing relationships and re-entering into the world as a sober individual to stop substance abuse.

What Is Contingency Management Therapy?

Contingency Management Therapy is an evidence-based therapy, meaning it’s accepted as a treatment based on research backing its effectiveness. Contingency Management involves a person who is recovering from drug or alcohol addiction receiving a reward for sobriety. The concept of the therapy revolves around the belief that environmental, social, and biological factors all influence substance abuse. It creates a rewarding experience for the person and provides that high or excitement that those who use substances desire.

Contingency Management Therapy is the same concept behind some people’s parenting technique. It’s used in schools and athletic programs as well as at jobs. When a person does well, that individual receives an award. Scientists have developed an entire therapy based on the idea of giving rewards for positive behaviors. The scientists Edward L. Thorndike and B.F. Sinner developed the concept. They both had an understanding of animal behavioral experimentation and used in when testing their theory. In the late 1940s and throughout the 1950s, students of Skinner began to use this particular therapy for those who have schizophrenia, behavioral problems, or developmental delays.

Unlike 12-Step programs that give tokens for each milestone, the person in a Contingency Management recovery program earns prizes or vouchers that are useful to the person. Oftentimes, the person is given vouchers that may be used to purchase food, movie tickets, or other services or goods. On the other hand, some programs provide individuals with an opportunity to win a chance to earn prizes. This particular structure curves the expense of the program since for each goal a person hits, they receive a chance to win a prize. The prize can range in value from a small amount of money to a television, states psychologist Nancy M. Petry in her book, Contingency Management for Substance Abuse Treatment: A Guide to Implementing This Evidence-Based Practice. The amount a person can earn over the course of the program varies, but sometimes, the total reaches $1,000 or more over a 12-week program. Some programs offer housing and behavioral therapy in exchange for meeting certain goals. Generally, to earn a reward of any kind, the person must comply with certain requirements, such as the following:

  • Giving a clean urine sample
  • Remaining drug- and alcohol-free
  • Attending meetings
  • Taking medications as prescribed

The entire concept of this therapy revolves around the theory that a person will want to continue to earn rewards for positive behaviors; therefore, the person will continue those behaviors throughout the program and potentially after completion of the program. On the contrary, the person will not want to lose out on the perks when negative behaviors are exhibited; therefore, the person will not repeat those behaviors. Not only will the person miss out on the prizes or vouchers when the individual doesn’t comply, another punishment may occur. Behaviors that go overlooked or ignored begin to decrease because there isn’t a punishment or reward associated with them. Eventually, these behaviors are reduced or eliminated. Basically, it reinforces the benefits of positive behaviors while attempting to correct negative behaviors at the same time.

Generally, punishments are only given when a person severely breaks the rules. Too many punishments have the potential to:

  • Deter the person from wanting to continue
  • Damage the relationship between the person and the one giving the rewards
  • Lead to secrecy regarding substance abuse
  • Have the opposite effect on some clients

The rewards start out at low values, but the therapist informs the person the vouchers will increase in value over time. In other words, the person receives more rewards as the number of clean urine samples add up, for example. Ultimately, this gives the person the incentive to want to stay clean for a longer period of time in order to obtain the higher-valued vouchers or prizes.

This particular type of treatment is most commonly used in treatment programs that last three months or longer. This is so a person has the time to earn enough rewards that the individual feels accomplished. Without the person feeling satisfaction from the rewards, the therapy isn’t effective.

Who Should Use Contingency Management Therapy?

Most commonly, this type of therapy works for those suffering from an opiate addiction, but, as noted by the National Institutes of Health, those who abuse stimulants like cocaine tend to benefit as well. A therapist may also use it for those addicted to another drug or alcohol.

The therapy isn’t as well-known as some other forms of treatment, such as Cognitive Behavioral Therapy. And because not all therapists have the ability to perform it, it isn’t prescribed frequently. Therefore, those who have not had success with other forms of treatment and therapy should consider Contingency Management Therapy.

Low-income individuals tend to benefit greatly from this form of treatment. Adolescents and teenagers who suffer from a substance abuse disorder may benefit also.

Who Should Not Use Contingency Management Therapy?

Not every client should opt for this type of therapy. Some may not find the rewards as appropriate motivation to succeed. The rewards might not be elaborate enough to drive the person into success. In some cases, the client feels strongly about recovery and doesn’t need the extra motivation. Clients are sometimes drawn to programs that take less time and don’t require clinic visits, so Contingency Management isn’t always an attractive option for everyone.

Those who are part of a co-occurring disorders treatment program for gambling may not benefit from this approach, especially since some criticize it for encouraging gambling. Those who have a highly addictive personally in general may become overwhelmed with the desire to earn rewards. Additionally, it doesn’t serve as effective addiction treatment on its own; it must be combined with traditional therapy that addresses underlying issues and co-occurring disorders.

There is limited research on the effects of Contingency Management Therapy and alcoholism. Because testing for alcohol is limited because of time restrictions, a breath alcohol test may only detect alcohol 4-12 hours after use, so it’s easy for results to be inaccurate. Blood alcohol tests are more invasive and don’t have much better results, as noted by Stephen T. Higgins (PhD) and Nancy M. Petry (PhD)’s Contingency Management: Incentives for Sobriety

How Much Is Contingency Management Therapy?

The price of therapy is affected by certain variables, such as the number of sessions required and the number of medications needed. The price for Contingency Management is higher than most other forms of treatment. One reason for heightened price is that prizes cost money. In some cases, this variety of treatment is outside the budget.

Does Insurance Cover Contingency Management Therapy?

Contingency Management isn’t always covered by insurance. Because of the high cost of Contingency Management Therapy, it’s not typically covered in full, if at all. Check with the treatment center and your specific policy prior to beginning therapy to ensure you’re aware of your exact level of coverage.

Is Contingency Management Combined with Other Treatments?

Contingency Management is effective for many clients; however, generally, a rehabilitation program will combine one or more other approaches into a treatment plan to craft the most effective course of action for each client. For instance, a client may receive treatment under a Contingency Management plan that requires the client to submit to biweekly urine specimens to obtain rewards while the client is also responsible for undergoing Cognitive Behavioral Therapy to address underlying issues. Combining more than one treatment targets the addiction from multiple angles. Generally, a professional evaluates the client and determines what may be the most effective course of action.

How Effective Is It?

The National Institutes of Health’s National Institute on Drug Abuse declared Contingency Management Therapy as an effective way to treat a substance use disorder, and it has a high rate of success. Per Contingency Management: Incentives for Sobriety, these experts conclude this therapy is an effective method of treating substance use disorders. In fact, Petry and Higgins’s essay concluded Contingency Management is effective and helps individuals participate in group meetings and to stay sober.

Proper implementation is vital for the person’s outcome. Clients have to be monitored continuously and reinforcement must be given continually for a client to want to continue meeting objectives. The most successful programs tend to include prizes and vouchers of $1,000 or more, as noted by Psychiatric Times.

Psychiatric Times published material citing a study conducted on cocaine-dependent outpatients undergoing a 12-Step treatment program or a Contingency Management program. In the Contingency Management treatment, clients received individualized behavioral therapy along with vouchers for every drug-free urine test. The study concluded those assigned to the Contingency Management group remained in treatment for a significantly longer period of time and decreased their cocaine use at a rate similar to those in the 12-Step program.

Another study was conducted to prove it was the use of vouchers that drove clients to refrain from drug abuse versus whether the behavioral therapy was responsible. Results revealed three-quarters of the individuals in the voucher conditioning programs completed the program while only 40 percent who received behavioral therapy without vouchers completed the program. The vouchers attributed to more than 50 percent of clients who underwent Contingency Management therapy attending the program for at least 10 weeks and remaining cocaine-free during that time. On the other hand, only 15 percent of individuals who didn’t receive vouchers finished the 10 weeks and achieved 10 weeks’ worth of clean urine samples. The study showed significantly better results for clients who underwent contingent conditioning, as they achieved prolonged periods of time when they were cocaine-free.

According to one review of 47 different studies Contingency Management was shown to contribute to an improvement in drug abstinence rates when combined into substance use disorder treatment programs. Moreover, the effectiveness rate of the programs appeared higher for treatment of cocaine and opiate addiction than other substance abuse.

Other research suggests the use of Contingency Management Therapy in an outpatient setting keeps those with a substance use disorder in the program. It’s not uncommon for those attending an outpatient program to miss scheduled appointments. In fact, it’s estimated that the number of missed appointments may be as high as 60 percent. One study showed the impact of giving vouchers for prizes like money or DVD players had an impact on attendance rates for outpatient programs. The study denoted those recovering from a substance abuse problem were more likely to attend weekly sessions when prizes were used to reinforce attendance, in particular when compared to programs that were not providing any type of reinforcement. Another study concluded that 84 percent of outpatients in a substance abuse treatment program committed to and completed an eight-week program when vouchers were given for attendance. This percentage is in comparison to the 22 percent who remained in programs of the same length but were not given vouchers.

Nancy M. Petry’s article, published in the British Journal of Psychiatry and later added to the National Institutes of Health’s database, documented a study conducted in the US on more than 800 individuals who were undergoing treatment for a stimulant use disorder. These individuals were from 14 clinics. People were either in a group who only received standard care, such as Cognitive Behavioral Therapy, or from the other group that consisted of individuals who received the standard level of care along with a Contingency Management program. In the Contingency Management program, the clients were subjected to biweekly urine sample testing lasting for 12 weeks. Individuals in the Contingency Management program were given the opportunity to draw from monetary prizes, ranging from $1 to $100. For each negative test, the person earned one chance to draw from the prizes, along with an increased number of draws as the number of drug-free samples continued. Half of the study was conducted on psychosocial (non-methadone) clinics while the other half came from methadone clinics. Contingency Management incorporated in a psychosocial program had a positive effect, as evident by the 49 percent of individuals who completed the 12-week program with contingent rewards. On the other hand, only 35 percent of the standard care group completed their 12-week program. In the Contingency Management group, the mean number of weeks of abstaining from stimulants was 4.4 while the group who received standard care only remained drug-free for a mean of 2.6 weeks. The percentage of clients who remained abstinent from drugs throughout the entire 12 weeks was nearly four times greater in the Contingency Management group, with 18.7 percent avoiding stimulant use in that group and only 4.9 percent remaining drug-free for 12 weeks in the standard care group. In the methadone clinic group, individuals continued treatment for longer than those in the standard care group.

Ultimately, Contingency Management can be a successful addition to a comprehensive treatment program for those suffering from various types of addictions.

About The Contributor
Editorial Staff
Editorial Staff, American Addiction Centers
The editorial staff of Greenhouse Treatment Center is comprised of addiction content experts from American Addiction Centers. Our editors and medical reviewers have over a decade of cumulative experience in medical content editing and have reviewed... Read More