Contingency Management: Benefits, Goals & Expectations

Children, teens and adults can all benefit from contingency management therapy as a way to earn rewards for completing desired behavioral changes.

When someone seeks treatment for their mental health or substance use disorders, they can encounter a variety of therapeutic styles conducted by the therapist. Although new therapies are developed continuously, some of the most effective strategies have been available for decades.

One effective treatment for numerous mental health and addiction issues is called contingency management (CM) therapy. If a person needs to change an unwanted or unhealthy behavior, contingency management therapy is often effective.

What Is Contingency Management?

Like cognitive behavior therapy (CBT) or psychodynamic therapy, contingency management is one style of therapy used by psychologists, social workers and counselors to improve their clients’ symptoms and overall well-being. As long as the therapist has adequate training and supervision in contingency management, they can effectively use this therapeutic style.

Unlike other therapies, contingency management involves a singular interest in the person’s behaviors. There is no attention paid to the thoughts or feelings because these facets are seen as inconsequential.

With the focus on behaviors, contingency management is a great therapy choice for people engaging in undesirable or dangerous behaviors. So, if someone has been engaging in self-harm, substance abuse, disordered eating, aggression, violence or other problematic actions, contingency management treatments could be ideal.

A benefit of contingency management is that the treatment is helpful for a wide range of people. From young children to older adults, contingency management can improve symptoms in people of almost any age.

Contingency management therapy can serve as a stand-alone intervention, or it can be integrated with other theoretical orientations like CBT or motivational interviewing to create a well-rounded approach. In this example, CBT and motivational interviewing would be used to address the person’s thoughts and feelings, while contingency management techniques could improve their unwanted behaviors.

How Does Contingency Management Work?

Contingency management is a form of therapy based on the behavioral principles of operant conditioning. In operant conditioning, the therapist or researcher pairs a valuable reward with a behavior to increase the frequency of the wanted action. In time, the reward is reduced and stopped, but the desired behavior continues. It works on the belief that people are willing to make significant changes if they are adequately rewarded for their behaviors.

In this form of treatment, the therapist armed with contingency management skills will work with the client and their family to devise a plan that finds rewards for wanted behaviors. A person who engages in prosocial or recovery-focused behaviors will receive a tangible reward for their actions, while someone who engages in unwanted behaviors will receive nothing.

Principles

The basis of contingency management is simple, but finding the best combination of rewards and behaviors is challenging. For the best contingency management plan, the treatment team will investigate the core principles of contingency management, including the:

• Target behavior
• Target person or group
• Reward
• Intensity of the reward
• Frequency of the reward
• Time the reward is given
• Length of treatment plan

All these factors must be working in harmony to create the desired effect. If the reward is not reinforcing enough or the target behavior is too challenging, the person will not be interested in changing

Scientific Evidence

For many years, contingency management has been subjected to countless studies to assess its effectiveness. These studies consistently show contingency management to be a useful therapeutic tool. Studies show that contingency management helps people stay in treatment longer and achieve their treatment goals.

With contingency management being based on the concept of the scientific principles of operant conditioning, it is no surprise the treatment is consistently effective.

Who May Benefit from a Contingency Management Program?

Contingency management is a versatile tool, which makes the treatment a great fit for a variety of people with a variety of presenting problems. In short, many people can benefit from contingency management.

Contingency management therapy is often used to treat mental health conditions like depression, anxiety and eating disorders. Many therapists who work with children will also use and teach contingency management skills to parents.

Children with conditions like attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder tend to respond well to contingency management interventions, especially when parents reinforce desired behaviors at home. In this way, children and parents both benefit from contingency management strategies. The children receive desirable rewards, and the parents receive the kind of behavior they want from their children.

Recently, the use of contingency management in substance abuse treatment is on the rise. Since substance abuse involves getting a rewarding feeling from negative behaviors, professionals use contingency management to reward positive behaviors.

Motivational incentives in substance abuse treatment are recommended for numerous substance use disorders, including those involving:

• Alcohol
• Stimulants like cocaine, crack and methamphetamine
• Opioids
• Nicotine

Types of Contingency Management Programs

Although all contingency management plans involve the parent or therapist providing a reward to the client when they complete a wanted action, not all contingency management programs are identical. There are two main types of contingency management programs: voucher-based reinforcement and prize incentive programs.

Voucher-Based Reinforcement

Voucher-based reinforcement (VBT) is mostly used with adults who abuse opioids, stimulants or both. In VBT, the person receives a voucher each time they submit a clean urine sample. Patients can exchange these vouchers for goods and services like food, movie passes and music.

At the beginning of VBT, the vouchers earned have little value, but as the period of abstinence increases, the vouchers grow in value. This way, the reinforcement gained from continued sobriety offsets any perceived benefit seen in relapse.

Prize Incentives

Prize incentives use a similar structure as VBT, with participants earning chances to receive prizes for each recovery-focused behavior they complete. Rewarded recovery-focused behaviors typically include:

• Clean urine screenings
• Attending support group meetings
• Participating in therapy sessions
• Completing community service hours

For every successful activity, the person receives one chance to reach into a bowl and pull out a prize written on a piece of paper. The variability of prize incentives adds an element of excitement and uncertainty, as the person has no idea what their reward will be.

Benefits of Contingency Management in Addiction Treatment

The benefits of contingency management in addiction treatment are numerous. Anyone looking for professional intervention should consider contingency management in substance abuse treatment.

To begin, contingency management treatment is readily available. Since many therapists receive training and supervision in contingency management, it should not be challenging to find a professional willing to provide these services. Contingency management is available in schools and the community as well.

The effectiveness of motivational incentives in substance abuse treatment is backed by decades of research. A person beginning the service can feel reasonably comfortable in knowing their symptoms will improve with the approach. Because contingency management is a widely-regarded as a beneficial treatment, insurance companies are happy to cover the services.

Perhaps the greatest asset of contingency management is the low risk. As long as the treatment provider does well to assess the situation appropriately and follows the principles of contingency management, the client is not in danger of any hazard or harm.

Barriers to Effective Treatment

Despite all of the benefits, there are still some barriers to effective contingency management treatment. Being aware of these can help the client, their family and the treatment provider overcome issues to increase the possibility for desirable outcomes.

Some barriers to contingency management include:

Long-term financial cost

As mentioned, contingency management rewards tend to start small and grow in value as time goes on. This increase in reinforcement means that successful clients will be more expensive to treat as time goes on. The financial strain could create problems for the treating therapist or facility.

External reinforcement may reduce internal motivation to change

Critics of contingency management may claim that rewarding someone reduces their internal motivation to change, which implies they only comply with treatment to receive reinforcement. Critics fear that substance use will restart when rewards are gone. While this pattern could emerge, it’s important to keep in mind that external rewards can also help clients gradually develop internal motivation to remain substance-free.

Reinforcers could be exchanged or sold for drugs or alcohol

For some people, having money and valuable items are triggers for use. Once people earn their reward from contingency management, they may be tempted to use the reward to obtain substances.

Does not address the root of the addiction

People may say contingency management is ineffective because it does not target the underlying causes of addiction and only focuses on the person’s behavior.

Could encourage gambling

If someone has a history of problematic gambling, contingency management may not be the best treatment option.

Although contingency management will not be a great fit for all people, most benefit from this treatment style despite the barriers.