Contingency management may be to help with the treatment of substance use disorders per clinician’s discretion.
Contingency management can be especially beneficial for individuals who are unable to take certain medications for managing addiction or for those who only have limited success using these treatments. Used with medications and/or other addiction treatment therapies, contingency management may increase treatment retention rates and improve a client’s chance of sobriety and recovery success.
Contingency Management Rewards Healthy, Sober Living
Humans, by nature, are wired to pursue activities and behaviors that create a sense of reward. Reward, then, enforces these behaviors, encouraging a person to repeat it in the future. This is called positive reinforcement. This is largely why substance abuse becomes so attractive to a person once they abuse drugs or alcohol.
With healthy, natural rewards, such as wholesome food, water and nurturing, this reward system can be beneficial. However, in the case of substance abuse, activating this reward system can be devastating.
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Drugs and alcohol stimulate the reward and pleasure centers of the brain by producing a chemical neurotransmitter called dopamine. Dopamine is responsible for producing the trademark buzz, euphoria, high, rush or other pleasurable feelings many drugs create.
In order to recreate these effects, many people consume the drug again. Eventually, as a tolerance occurs, the amount of drug needed to produce these feel-good effects climbs, circumstances which can push a person closer to addiction. For a person in treatment, or in the beginning stages of recovery, the absence of a drug-induced reward can be intimidating. In fact, the longing for reward sensations is a major factor in relapse.
Part of treating addiction revolves around normalizing brain function as best as possible and teaching a person to find healthier ways to experience reward and pleasure. After an addictive lifestyle, it can be difficult for a person newly in recovery to experience a sense of reward or pleasure while sober. Contingency management can be a useful tool in fighting this state.
Through a system of positive incentives, a person is taught to appreciate non-substance-related rewards. Not only do these rewards encourage abstinence and healthy behaviors, but they also boost self-confidence, a much-needed change after the poor morale caused by addiction.
What Is A Contingency Management Program?
Contingency management is founded on operant conditioning, a concept that people learn and change based upon rewards and punishments for their behaviors. People respond positively to incentives, and in the case of substance abuse treatment, this system of behavior modification has shown great success.
Contingency management uses rewards to reinforce behaviors that support both facility requirements and a person’s individual recovery and sober living goals. Quite often these goals include negative urine tests or breathalyzer results, however, a program may also use incentives to reward treatment attendance or educational, social or vocational goals. One study even found that contingency management incentives increased the number of high-risk injection drug abusers who completed hepatitis B vaccination programs.
In addition to being used in inpatient drug rehab programs, contingency management is frequently used in community-based treatment programs, including traditional outpatient, intensive outpatient, partial hospitalization and methadone maintenance programs. In this role, outpatient programs are generally best used as a step-down service from a residential treatment program.
What makes contingency management stand apart from other treatment approaches is the emphasis on positive reinforcement versus punishment. Some treatment facilities foster a negative environment by using confrontational techniques when a person doesn’t adhere to program guidelines. These procedures can alienate a person from the therapeutic community of treatment, break their self-confidence and reduce their motivation for change.
Instead, contingency management uses a more supportive form of negative consequences. Specifically, if a person fails to meet their goals or has a positive drug test they would not receive a voucher or prize. When compared to confrontational techniques or punishments, using rewards to support positive behaviors can have a more inspiring and lasting impact.
How Does Contingency Management Work?
Once individualized treatment goals are established and agreed upon, a written contract may be drawn up. This contract holds a person accountable and outlines the arrangements of the contingency management program.
Two forms of motivational incentives or rewards-based systems widely used in addiction treatment include:
Voucher-Based Reinforcement: In this method, participants receive a voucher for each drug-free urine sample or negative breathalyzer result. Each voucher has a cash value that may then be used to obtain various goods, services and/or retail items that can be part of a balanced, sober life. Examples include clothing, electronics, food, movie passes and restaurant gift certificates. As a person continues to have negative test results, the value of the vouchers increase.
The National Institute on Drug Abuse (NIDA) reports that this method is beneficial for individuals addicted to opioids and stimulants, with particular benefit for people with a cocaine use disorder.
Prize Incentives: It’s recommended that these programs last three months or more. In this time, at least once a week, clients draw from a “fishbowl” for a cash prize. Certain slips may offer words of encouragement only, while others have prizes ranging from a dollar to a hundred dollars or more.
According to the NIDA, research has shown that prize incentives do not encourage gambling behaviors in treatment participants.
Treatment providers may also offer extra privileges to clients as an additional way to reward healthy behaviors.
If there’s a missing or positive sample, positive reinforcement is typically withheld, an action that is sometimes referred to as a punishment. For instance, if a person has a positive urine sample they would not receive a slip or chip for a cash prize drawing. In the voucher system, should a person test positive, they would start over at the lowest voucher value.
Contingency Management And Integrated Care
Like many forms of addiction treatment, especially other forms of behavioral therapy, an individual may have greater success when contingency management is coupled with other therapies.
While contingency management is effective, intensive psychotherapy sessions are often necessary to help a person overcome the root causes of addiction. This integrated approach typically includes additional behavioral therapies, such as cognitive-behavioral therapy.
Contingency management may be helpful for co-occurring disorder treatment when a person has both a mental health and substance use disorder.
- American Psychological Association — Accentuate the Positive: Vouchers Help Drug Abusers Stay in Treatment
- The Lancet — Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomized trial
- US National Library of Medicine — Contingency management treatments decrease psychiatric symptoms