Contingency Management in Substance Abuse Treatment
There are many different ways to stay motivated, and different people are inspired by different things. For some people, making a goal with a clear end is enough. For others, knowing that they can make their family proud is motivational. For those people who are struggling with addiction, simply wanting to achieve sobriety often isn’t enough. When it comes to addiction, the risk of losing everything might not be enough. In addiction recovery, the patient has to be motivated on their own and for themselves. People in recovery need to find ways to stay motivated. Contingency Management (CM) is a way people in recovery can maintain discipline. CM offers motivational incentives that are effective in keeping people inspired. CM is also referred to as “the prize method”, “motivational incentives”, and “the carrot and stick method.”.
Operant Conditioning Principles
The motivational incentives involved in CM are based on the concept of “operant conditioning,” behavior shaped by consequences. Operant conditioning involves “behavioral interventions that provide or withhold rewards and negative consequences quickly in response to at least one measurable behavior.” Behaviorists B.F. Skinner and John Watson are credited with establishing operant conditioning in psychological history. They theorized that “behaviors are shaped by their consequences; they will increase over time if followed by a pleasant experience (reward) or decrease if followed by an unpleasant experience (punishment).” The principles that surfaced from operant conditioning can be applied to addiction treatment. The way drugs work in the body is a natural, biological example of operant conditioning. Drugs create rewarding biochemical influences which contribute to addictive behavior.
CM and Drug Abstinence
Because drugs offer neurobiologically rewarding effects, they can be difficult to combat. It presents a challenge, but not an impossible one. Contingency management gives people the opportunity to get their life back on track and maintain abstinence from drug use. Once discipline is introduced and accepted, all of the benefits of a sober lifestyle outweigh any biological pleasure derived from drug use.
How do we measure recovery? Drug tests called toxicology screens are used to determine whether a person has used drugs or is still sober. Patients who practice CM feel empowered by their ability to remain abstinent and incentivized to remain strong and committed to recovery.
Researchers in the 1960s were inspired to investigate how CM intervention could help people with alcohol use disorders stay sober. As more information about contingency management became available, other treatment approaches began to incorporate its principles. The Community Reinforcement Approach (CRA) includes the operant conditioning principles from CM as well as incorporating healthy socialization and coping skills.
Throughout the 1990s, the contingency management approach grew in popularity, with numerous studies demonstrating that it is an effective way to influence drug addicts and increase abstinence among clients with cocaine use disorders. Research published in the Archives of General Psychiatry outlined how CM, combined with medication like methadone, can help encourage drug abstinence. The article outlines how “a variety of incentives have been shown to decrease illicit drug use in patients enrolled in methadone maintenance programs.” Researchers believe that contingency management is effective because of the external control (ability to control consequences by one’s actions) which assists patients to practice self-control.
Contingency Management in Recovery
The sobriety chips given to members of Alcoholics Anonymous (AA) for being sober for a certain amount of time are a well-known application of CM. Interventions in any CM involve people receiving either a reward for reaching a goal or a negative consequence for not working toward their goal. In drug rehabilitation, individuals treated with CM care plans receive rewards for a negative urine toxicology screen. Depending on the patient, the reward for achieving a clean test might include vouchers, gift cards, food, privileges, and most importantly, the respect of the community. This prize reinforcement creates interesting dynamics at rehab centers, as the longer clients stay sober, the more respect and privileges they gain.
Contingency management is a treatment approach that can last a lifetime and can be applied outside of a clinical environment. It can remain a lifelong resource in a client’s continuing journey to recovery. Parents, spouses, and friends can all support those in recovery by celebrating negative toxicology screens and encouraging continued abstinence from substance use.
A CM approach has been used in some states to address the legal consequences of alcohol-related criminal justice offenses. Offenders may be allowed to live at home and avoid jail as long as they remain sober. They are required to be tested daily with a breathalyzer or with an alcohol skin sensory monitor. These individuals are constantly monitored and if they test positive for alcohol use, the reward will be withdrawn and consequences will be applied, like a few days in jail. While it might seem like a softer consequence, transparency is what makes this “approach a highly beneficial and cost-effective one for multiple DUI offenders.”
Does Contingency Management Work?
While some people are skeptical about this alternative approach, the results from clients in recovery with a CM system show increased abstinence rates. These positive results support the use of prize reinforcement in substance use disorder recovery. CM has also been shown to enhance adherence to psychological treatment and medication guidelines. Many treatment centers are worried about introducing CM management to their care plans because the rewards could be classified as “a game of chance,” but there is no evidence to suggest that CM incites gambling behavior. Some facilities may have moral objections to using CM treatment, arguing that recovery should not be incentivized, it should come from within.
Getting rewards for good behavior may seem childish, but it has proven useful with adults. The adolescent population of patients has also benefited from an incentivized approach. Particularly, among the adolescent population of patients, CM in combination with other forms of therapy has provided empirically supported results. Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT) have been proven effective in encouraging abstinence when combined with a CM approach. For the adolescent population, there is usually a built-in support system; parents can be effectively trained “in the rationale and delivery of CM interventions.”
At Boardwalk Recovery Center, we assess the needs of each client and apply a care plan that aligns with their needs and what motivates and incentivizes them to remain abstinent.