Contingency Management: The Pros, Cons, and Details

Last Updated: October 4, 2021

Authored by Nena Messina, Ph.D.

Reviewed by Michael Espelin APRN

In the management of psychological conditions such as addiction, various therapies and techniques can be used to break the hold that the condition has on the individual. One of these therapies is known as contingency management intervention (CM).

Contingency management interventions can be integrated into the rehabilitation process for those dealing with substance abuse to facilitate a higher chance of recovery. This article will discuss the use of this technique, its efficacy, and the advantages and disadvantages it presents.

What Is Contingency Management?

CM is a behavioral therapy program that focuses on rewarding positive or desired behavior to reinforce and establish a more permanent behavior change.

When a person undergoing contingency management therapy meets a goal or a target relating to their recovery, they are allowed or given a reward that serves as a means of encouragement, reinforcement, and conditioning. It is helpful for patients who lack the motivation to remain abstinent. Unlike motivational interviewing training (MI) or motivational enhancement therapy (MET), the main purpose of CM is not to motivate positive change, but rather to maintain it.

Excited woman smiling, working on the laptop.

It is important to keep in mind that CM is not only limited to drug and alcohol treatment. It can also be used in those dealing with other health conditions, such as people with eating disorders, or to help with treatment adherence.

Science Behind Contingency Management Therapy

This therapeutic method draws from the same principles of operant conditioning, which essentially concerns how behavior can be conditioned due to rewards or punishments paired with them. In the case of CM, behavior is rewarded and never punished.

It has been proven that behavior can be reinforced with the use of incentives, and the closer the timing of the reward to the performed behavior, the more likely that behavior will be performed. In addiction treatment, this behavior may be clean tests or other means of proving abstinence or regularly attending treatment or 12 steps to recovery meetings.

Contingency Management Program in Addiction Treatment

When this program is applied directly to the treatment of drug addiction, it is most effective when executed in a precise manner, which is why it is best to contact professionals before commencing.

In addiction treatment, the means of judging successful abstinence will typically be regular urine samples tested for potential substances of abuse. A person who has maintained abstinence, as proven by their urine tests, will be rewarded with monetary prizes.

A technique that can be applied to improve the efficacy of this therapy is increasing the strength of the reinforcement. In this case, the value of the prizes or vouchers, as the addict increases the duration of their abstinence. It will enhance the individual’s desire for longer stretches of abstinence while still providing the subconscious benefits of the conditioning.

There are two major principles of contingency management interventions, which are voucher-based reinforcement and prize incentives.

Voucher-Based Reinforcement

In this principle, a drug addict is provided with a voucher that can be used for several purposes, including movies, shopping, or food, only when they are able to provide a urine sample that tests negative for any substance of abuse.

Happy excited woman received a voucher.

The value of these vouchers continues to increase as the individual increases the duration of their abstinence, which helps to provide further motivation for recovery. Relapse will result in the patient being reset back to the initial value of voucher incentives.

Prize Incentives

This principle is quite different from the form based on vouchers as it does not guarantee the same or increasing value or prize. In this case, the patient’s negative tests are rewarded with the chance to draw a prize that can be worth anywhere between $1 and $100.

As they progress through substance abuse treatment, they get more chances to draw for a prize, giving them a better chance to get higher-value rewards.

The major downside to this method is the risk of promoting gambling due to the involvement of chance and winning prizes, though studies have not been able to demonstrate this risk.

Pros and Cons of Contingency Management Interventions

Although it may sound like it can only be advantageous, there are pros and cons to this therapeutic method. The disadvantages, in particular, should be properly considered by anyone who is looking at this type of therapy in the treatment of their substance abuse.

Advantages

The benefits of this therapy can be easily appreciated. For instance, it is recommended by the National Institute for Health and Care Excellence in the United Kingdom. Considering several contingency management examples in studies, they concluded that proper implementation would reap benefits for society as a whole.

Besides its direct effects on treating addiction, it has also been shown to assist in the peripheral goal of ensuring the completion of hepatitis B vaccination in those being treated for addiction to heroin. It also has a positive impact on patients and their attendance at their appointments.

There is also a proven benefit for healthcare providers. It was shown in one study that alongside an increase in the morale of the participants, there was a corresponding increase in the morale of the personnel involved. It was also shown to improve the relationship between the staff and their patients and the relationship between staff members.

Disadvantages

The same 2014 study that showed advantages for short-term abstinence also found that the benefits for a contingency management program did not seem to persist beyond the six-month mark, though not all other studies reached the same conclusion.

There are several barriers to more widespread implementation, including personnel reservations based on the worry of more intense workloads, the ethical debate regarding this method of therapy, and the impact such treatment may have on the staff-client dynamic.

In some centers, this therapy cannot be implemented due to insufficient resources, either monetarily or in terms of trained personnel. It has been found that limited funds for rewards reduce the efficacy of this type of therapy. As a result, it tends to be reserved for centers in higher-resource settings.

Efficacy of Contingency Management Examples

These are some studies where CM was practiced and where the efficacy can be well-demonstrated.

Among other contingency management examples, a 2014 study involving patients with heroin dependence undergoing hepatitis B vaccination showed that 45% to 49% of the patients involved in the CM met the target for vaccination as opposed to a mere 9% of those treated with the usual methods.

In patients comorbid for smoking and depression, 53.3% of these patients showed significant improvement when compared to those who did not have contingency management therapy, at just 23.3%

Getting Successful Treatment

CM provides a means of improving an addict’s motivation for treatment as well as subconsciously conditioning them to remain abstinent.

The efficacy of this treatment has been well-proven, and despite barriers to entry, it is bound to find wider adoption due to clear evidence of its effectiveness. Contingency management therapy should be considered by any individuals struggling with motivation for maintaining abstinence, and contacting your closest treatment center can get you started on the path to recovery.

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Published on: October 4th, 2021

Updated on: October 4th, 2021

About Author

Nena Messina, Ph.D.

Nena Messina is a specialist in drug-related domestic violence. She devoted her life to the study of the connection between crime, mental health, and substance abuse. Apart from her work as management at addiction center, Nena regularly takes part in the educational program as a lecturer.

Medically Reviewed by

Michael Espelin APRN

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.