What is Contingency Management Therapy?

Contingency management (CM) is a type of cognitive-behavioral therapy. It involves the use of cash prizes and vouchers to reward good behavior. Patients are rewarded for things such as 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

Contingency Management Intervention: How The Program Works

There are two primary CM incentives: vouchers and cash.

1. Voucher-Based Reinforcement (VBR)

With VBR, patients receive vouchers for every drug-free urine sample that they provide. These vouchers can be exchanged for various goods or services in line with a drug-free lifestyle. 

Items 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. If the patient fails a drug test, the vouchers reset to their initial values. 

2. Prize Incentives CM (PICM)

Instead of vouchers, PICM utilizes cash prizes to reward patients. 

Over the course of three months, participants provide weekly drug-negative urine or breath tests or complete goal-related activities. 

In exchange, they get to draw for the chance to win small cash prizes. The value of these prizes ranges from $1 to $100, increasing in value with repeat good behavior.

However, the prize money resets to $1 if the patient fails to meet a goal or pass a drug test. 

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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 

In order to save resources, it’s essential to choose which patients or groups of patients receive incentives. 

Possible choices could include: 

• Individual patients 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 

This is a central aspect of CM. If a patient is uninterested in a particular reward, treatment is less effective.

Clinic staff can survey patients 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 offering enough incentive. Some need larger rewards to stay motivated.

5. Frequency of rewards 

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

It’s best to reward new patients 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 

Since the treatment goal is long-term sobriety, CM therapy takes longer for some people than for others.  

Ending treatment needs to be paired with relapse prevention strategies to reduce the risk of relapse.

Examples of Contingency Management

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. 

Examples of this include:

• Parents giving their children an allowance for doing chores
• School teachers assigning points (redeemable for prizes) to students who show good behavior
• Managers rewarding an employee with a promotion or salary bonus for good performance

Examples of Contingency Management in Substance Use Treatment

There are many ways CM can be applied:

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

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Advantages vs. Disadvantages of Contingency Management

As with other substance abuse treatment approaches, there are both advantages and disadvantages to CM therapy.

The advantages of CM include:

• Good success rate

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

The disadvantages 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 sound principles of behavioral therapy. 

It's highly effective for stimulant addiction. In one study, patients receiving CM therapy abstained for nearly twice as long as those that didn’t.⁷

Marijuana, heroin, methadone, and benzodiazepine are very treatable with CM.³

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

Treating Alcohol Use Disorder (AUD)

While commonly used to treat addiction to illicit drugs, CM was originally developed to treat alcohol dependence.

In an early study, researchers compared alcoholics who received CM treatment to those who didn’t. They found CM 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. It found that patients who received CM attended nearly twice as many sessions as the control group.⁵

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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 which 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 sessions as the control group.²

"Contingency management is a valuable adjunct for increasing retention in treatment among patients with dual disorders in partial hospitalization treatment. Exposure to contingency management increases retention in treatment, which in turn contributes to increased drug-free days."

— Contingency Management for Patients with Dual Disorders in Intensive Outpatient Treatment for Addiction

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