What Makes Contingency Management a Powerful Tool in Alcohol Addiction Therapy?

Contingency management (CM) is a type of cognitive-behavioral therapy based on the principle of operant conditioning. It involves using incentives such as cash prizes and vouchers to reward good behavior.

People are rewarded for accomplishments like having clean urine tests or adhering to psychiatric medication. Desired behaviors targeted by CM include:

• Abstinence
• Medication compliance
• Treatment engagement
• Lifestyle improvements

Despite a lack of familiarity from some in the substance abuse field, an extensive body of research backs CM’s effectiveness.³

The Seven Principles of CM Programs

There are seven principles that all CM programs follow:

1. Target Behavior

This means decreasing negative behavior and increasing positive behavior. 

Negative behaviors are those associated with substance use (such as buying or using). Positive behaviors include attending therapy and working on treatment goals. 

2. Choice of the Target Population

To save resources, choosing which persons or groups of people receive incentives is essential.

Possible choices could include:

• Individual people who need extra motivation to progress in treatment
• Users of a particular drug like heroin or methamphetamine
• Those with both addictions and co-occurring mental illnesses
• Younger addicts or pregnant women

3. Choice of Reward

The choice of reward is a central aspect of CM. Treatment is less effective if a person is uninterested in a particular reward. Clinic staff can survey people on what kind of things motivate them. 

Dispensing privileges can be another way to provide incentives without spending money. These may include parking spots or computer access. 

4. Reward Magnitude

With unlimited resources, CM programs could offer rewards without concern for cost. However, programs must work to find rewards that fit their budget while providing enough incentives. Some people need more significant rewards to stay motivated.

5. Frequency of Rewards

Some programs reward good behavior every time. However, others use a specified or variable rate.

It’s best to reward new people each time they show good behavior. After a while, the frequency can be reduced.

6. Timing

Timing is as important as frequency. Rewards given promptly build a strong association between the desired behavior and the reward.

7. Duration of Intervention

The goal of CM therapy is long-term sobriety. Because of this, CM therapy can take longer for some people than others. Ending treatment needs to be paired with relapse prevention strategies to reduce the risk of relapse.

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How Does Contingency Management Intervention Work?

There are two primary CM incentives⁠—vouchers and cash.

1. Voucher-Based Reinforcement (VBR)

These vouchers can be exchanged for various goods or services in line with a drug-free lifestyle. People receive them for every drug-free urine sample they provide.

These items for exchange include:

• Food
• Clothes
• Movie tickets
• Restaurant gift certificates
• Books
• Bus passes
• Coffee mugs
• Gas
• Electronics

The value of the vouchers starts low, increasing gradually with repeated good behavior. The vouchers return to their initial values if the patient fails a drug test.

2. Prize Incentives CM (PICM)

Instead of vouchers, PICM utilizes cash prizes to reward people. For three months, participants provide weekly drug-negative urine or breath tests or complete goal-related activities.

In exchange for consistently responsible behavior, people get to draw for a chance to win cash prizes ranging from $1 to $100. The cash prize increases in value for every repeated good behavior. However, the prize money resets to $1 if the person fails to meet a goal or pass a drug test.

Examples of How Contingency Management is Used

CM is based on a simple idea: if a behavior is rewarded, it’s more likely to happen again. This is known as positive reinforcement.

Positive reinforcement is often used to motivate children and adults. Examples include rewarding children with an allowance or giving an employee a salary bonus.

CM can also be applied in substance abuse treatment. Here are a few examples. 

• Every time a person tests negative for substances
• When a person attends therapy or applies for a job
• If a person takes medication every day for a week
• If a person shows altruistic behavior (ex: voluntarily helping another group member) 
• Job training or housing for continued sobriety

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What are the Pros and Cons of Contingency Management?

As with other substance abuse treatment approaches, CM therapy has advantages and disadvantages.

Pros of CM include:

• Effective strategy

• Rewards increase compliance
• It can be used in combination with other treatment options

Cons of CM include:

• Resources are not always available to give adequate rewards
• When reinforcement stops, there is a high chance of relapse
• Some are concerned that cash prizes could promote gambling

Contingency Management in Addiction Treatment 

CM is effective for most addictions, especially stimulants and opioids.² Addictions fall under two broad categories: substance use disorders (SUD) and alcohol use disorders (AUD).

Treating Substance Use Disorders (SUD)

CM is an effective treatment for SUD because it’s based on behavioral therapy principles. 

It's highly effective for substances like:³

• Marijuana
• Heroin
• Methadone
• Benzodiazepine

In one study, people receiving CM therapy abstained from addictive substances for nearly twice as long as those without.⁷

CM is also effective in treating people with co-occurring disorders.² This is when someone is diagnosed with a SUD and a mental health disorder.

Treating Alcohol Use Disorder (AUD)

CM was initially developed to treat alcohol dependence. In an early study, researchers found that CM treatment decreased arrests for public drunkenness by 82%.⁸

More recently, a study was done on CM’s effectiveness in treating co-occurring AUD and mental illness. Contingency management also promotes attendance to recovery-related appointments in people with substance use disorders.⁵

Contingency Management and Co-Occurring Disorders

If someone has both a substance use disorder and a mental health disorder, they have a dual diagnosis. These are complex situations that CM has been shown to handle effectively.

In 2017 the University of Pittsburgh analyzed CM's effectiveness with dual-diagnosis patients. It found that patients who received CM attended nearly twice as many coaching sessions as the control group.²

CM is a valuable tool for treating patients with dual disorders in partial hospitalization treatment. It can increase retention in treatment which contributes to increased drug-free days.¹

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Summary

Contingency management (CM) is a type of cognitive-behavioral therapy based on the principle of operant conditioning. It provides rewards such as cash or vouchers to incentivize sobriety.

The goal of CM is to promote long-term sobriety. By giving tangible rewards, CM provides much-needed motivation to people struggling with addiction. 

Although there are advantages and disadvantages to this program, it is effective. Studies show that CM an effective at helping patients with co-occurring disorders.

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