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Contingency management: definition, uses, principles, and addiction treatment

Reading time: 18 mins
Contingency management: definition, uses, principles, and addiction treatment

Contingency management is a type of behavior therapy where an incentive, reinforcement, or reward is distributed to the patient whenever they demonstrate a predetermined and desired behavior that aligns with the therapy goals.

Contingency management is used in clinical settings related to addictions, such as alcoholism, stimulant- and opioid use disorders, and smoking. It is used to treat behavioral issues like eating disorders, symptoms of conduct disorders in adolescents like aggression, and autism. It is used to promote pro-health behaviors like adhering to medications, diet plans, exercise routines, and weight loss programs, and refraining from engaging in HIV-risk conduct. It is used in scenarios where pharmacotherapy is not medically advised, such as when attempting to reduce smoking in pregnant women.

The principles of contingency management are target behavior, target population, nature of reinforcer or incentive, magnitude of reinforcer, timing of reinforcement, frequency or schedule of reinforcement, and duration of reinforcement.

Contingency management is effective in treating addiction by reducing substance use, enhancing therapy retention, improving adherence to medications, increasing attendance in counseling sessions and group meetings, and sustaining abstinence in diverse groups of populations and varied clinical settings. When used concurrently with other evidence-based treatment protocols to treat addiction, contingency management demonstrates more positive and enduring results than standard care.

What is contingency management?

Contingency management is a form of behavior therapy where an incentive, reinforcement, or reward is given whenever a predetermined and desired behavior that aligns with the therapy goals is demonstrated by the individual undergoing the treatment, per the APA Dictionary of Psychology published by the American Psychological Association and updated on 19 April 2018.

Contingency management is an evidence-based psychosocial therapy for treating various types of addiction, according to this release by the U.S. Department of Health and Human Services on 7 November 2023, titled “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention.” This therapy is provided as a treatment option by the U.S. Department of Veterans Affairs and in several grant programs run by the U.S. Department of Health and Human Services. It is covered by Medicaid in several U.S. states like California and Washington.

Where is contingency management used?

A man in black jacket with a therapist.

Contingency management is used in clinical settings related to substance abuse, autism, and conduct disorder in adolescents, according to this 2011 article by Nancy M. Petry published in the journal The Psychiatrist, titled “Contingency management: what it is and why psychiatrists should want to use it.” This 2005 entry by Bartholomew et al., titled “Contingency Management Strategy and Ideas,” and included in the National Registry of Evidence-based Programs and Practices (NREPP), published by the Substance Abuse and Mental Health Services Administration (SAMHSA) mentions that contingency management is used to treat behavioral problems like smoking, aggression, and eating disorders. A substantial amount of scientific literature points out that contingency management is effective in treating addiction(Petry, 2011).

According to this 2018 article by McPherson et al., published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” contingency management was first implemented for treating alcoholism.

In this 1999 article titled “Contingency Management: Incentives for Sobriety” published in the journal Alcohol Research & Health, authors Stephen T. Higgins and Nancy M. Petrynote that contingency management has been shown to reduce drinking, increase treatment adherence, and enforce medication compliance in alcoholics and people with problem-drinking behaviors.

In this 2022 article titled “Dissemination of Contingency Management for the Treatment of Opioid Use Disorder” published in the journal Perspectives on Behavior Science, author A. DeFuliomentions that contingency management is effective in treating opioid use disorder.

In their 2012 article titled “Contingency Management for Patients with Cooccurring Disorders: Evaluation of a Case Study and Recommendations for Practitioners” published in the journal Case Reports in Psychiatry, authors Adams et al., refer to several studies that have found contingency management to be effective in improving treatment attendance and reducing substance use in patients with addiction and co-occurring psychiatric disorders. Author Petry (2011) notes that contingency management is effective for patients with dual diagnosis who often display extraordinarily high rates of addiction.

For instance, several studies have found that this treatment approach is effective at reducing abuse of cocaine and marijuana in patients with psychiatric illnesses and holds promise for reducing smoking in people with schizophrenia. Authors Higgins and Petry (1999) note that contingency management has shown promising results in achieving abstinence in alcohol-abusing schizophrenics. In the section titled “Contingency Management (CM)” of the chapter “Cannabis Use Disorder” in the book Reference Module in Neuroscience and Biobehavioral Psychology published in 2023, authors Hsu et al., mention that contingency management helps treat cannabis use disorder when delivered with other treatment modalities like cognitive-behavioral therapy or motivational interviewing.

Authors McPherson et al., in their 2018 article published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” mention that contingency management has shown significant positive effects in several studies that targeted health-related behaviors, such as altering HIV-risk conduct, and promoting adherence to medication, exercise regimens, diet plans, and weight loss therapies.

In the section titled “Contingency Management” of the chapter Behavioral Treatments for Smoking in the book Interventions for Addiction published in 2013, authors Sheila M. Alessi and David M. Ledgerwood mention that contingency management is especially effective for individuals unsuitable for pharmacotherapy, such as pregnant women who smoke. They refer to studies where contingency management achieved significant smoking reductions in pregnant smokers, with the positive effects sustaining throughout the postpartum period.

What are the principles of contingency management?

A woman hiding her face with her hands.

The principles of contingency management are listed below.

  • Target behavior: Target behavior is the cornerstone of contingency management and grounds the framework within which reinforcements are distributed. A target behavior, also known as a “target” or an “outcome,” is a specific desirable behavior that the patient undergoing therapy is expected to demonstrate. The target behavior must be specific, observable, realistic, and aligned with the patient’s therapy goals. It should be set after involving the patient in the planning process. In the context of addiction treatment, these are behaviors that support recovery and abstinence. These include attending scheduled treatment and counseling sessions, taking the prescribed medications, taking part in recovery activities, and attending meetings held by mutual support groups, such as Narcotics Anonymous or Alcoholics Anonymous. Avoiding taking drugs or alcohol is a common target behavior in contingency management and one that targets abstinence directly. A negative drug test sample is proof of the patient demonstrating the behavior.
  • Target population: This refers to an individual or a group of people in a treatment program identified to receive the reinforcement. Maximizing available resources and outcomes is an important criterion for choosing a target population that will receive reinforcements. One approach is to choose sub-populations to target. In certain instances, these sub-populations comprise particularly vulnerable people. For instance, vulnerable groups within a population of substance-abusing individuals include pregnant women, adolescents, homeless individuals, people with dual diagnosis, and people with HIV, according to this 2011 article by Nancy M. Petry titled “Contingency management: what it is and why psychiatrists should want to use it” that was published in the journal The Psychiatrist.
  • Nature of reinforcer: This refers to the type of reinforcer provided to the target population. These include cash, vouchers, prizes, and access to clinic services like preferred times for appointments, special parking spots, the first choice of methadone dosing hours, take-home methadone doses, and computer privileges. Other privileges include access to social services and employment contingent on displaying the target behavior. The effectiveness of contingency management is determined by the choice of a reinforcer. Patients are most motivated to change their behavior if they perceive the incentives as valuable and desirable. A survey must be conducted among the target population to identify what they prefer to receive as prizes or privileges.
  • Magnitude of reinforcer: According to this 1984 article by Maxine L. Stitzer and George E. Bigelow published in the Journal of Applied Behavior Analysis, titled “Contingent reinforcement for carbon monoxide reduction: within-subject effects of pay amount,” increasing the magnitude of reinforcers increased the duration of abstinence in a study conducted on smokers. In the context of addiction, the amount or magnitude of the reinforcer depends on the nature of the target behavior and individual differences in the patient’s experience with substance abuse. These factors include the extent of the individual’s past and present drug use, how successful they were at abstinence, their responsiveness to earlier reinforcements as drivers of behavior change, and the quality of their social support network.
  • Timing of reinforcement: Reinforcement must be distributed as soon as feasible after the target behavior is demonstrated to prevent delay discounting from taking effect. According to this 2018 article by McPherson et al., published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” in the context of addiction treatment, delay discounting is the tendency of substance abusers to devalue positive reinforcement that they must wait to receive. The authors believe that there is a robust neurobiological basis for this tendency. Chronic substance abuse creates an imbalance in the neural networks of the drug user. Their amygdala system goes into overdrive and overrides the activities of the prefrontal cortex, an area of the brain that motivates the user to plan for and look forward to positive reinforcement. As a result, the individual becomes more motivated to seek immediate gratification in the form of drugs or alcohol.
  • Frequency or schedule of distributing reinforcement: This refers to how often the positive reinforcement is distributed and is determined by factors like target behavior, the relative ease or the challenges of measuring the behavior, the amount of clinical contact with the patient, and the resources available to carry out activities like testing for the target behavior and distributing reinforcements. For instance, abstinence is not a feasible target behavior to aim for if screening for drugs cannot be done frequently. So, it is prudent to schedule reinforcements using varied approaches in settings where it is not logistically or financially feasible to distribute reinforcements every time the target behavior is exhibited. This 2005 entry authored by Bartholomew et al., titled “Contingency Management Strategy and Ideas,” and included in the National Registry of Evidence-based Programs and Practices (NREPP), published by the Substance Abuse and Mental Health Services Administration (SAMHSA) mentions a real-life instance of an intermittent rewards schedule used in contingency management, the StarCharts system at the Texas Christian University developed to decrease cocaine use in individuals attending an outpatient methadone treatment program. The patients earned “stars” for every drug-free urinalysis report in a twice-monthly screening schedule, attending counseling sessions, and completing specified treatment-related tasks. Instead of rewarding the patients with a prize every time they demonstrated a target behavior, the stars they earned were displayed on a bulletin board in the counselor’s office, next to their clinic ID number. They were allowed to “cash in” the stars periodically for small prizes worth about $5 or save up the stars for a bigger prize, valued at $25 maximum. Providing a tangible reward, in this case, a star, immediately upon demonstrating a desirable behavior is based on the operant conditioning principle.
  • Duration of reinforcement: This refers to how long the reinforcements are provided to motivate the patients to exhibit the target behavior. One approach suggests stopping reinforcements after a fixed duration, which is decided in advance. However, there are studies mentioning that some patients relapse after reinforcements are terminated, according to this 2007 article by Silverman et al., in the Journal of Applied Behavior Analysis, titled “A Randomized Trial of Employment-Based Reinforcement of Cocaine Abstinence in Injection Drug Users.” It is challenging to comprehend in advance a duration that will produce the most effective results. For instance, according to this 2024 article by Ussher et al., published in the journal Addiction, titled “Effect of 3 months and 12 months of financial incentives on 12-month postpartum smoking cessation maintenance: A randomized controlled trial,” incentives provided for 12 months produced superior results than when incentives were provided for three months in a program for maintaining smoking abstinence in postpartum women. A flexible approach is to align reinforcement duration to the treatment response exhibited by the patient where the conditions needed to be fulfilled by the patient to receive reinforcement are gradually increased while decreasing the magnitude of the incentive.

What is the process of contingency management?

A man sitting with a female therapist

The process of contingency management is based on the principles of operant conditioning, according to authors Sheila M. Alessi and David M. Ledgerwood in the section titled “Contingency Management” of the chapter Behavioral Treatments for Smoking in the book Interventions for Addiction published in 2013.

According to McPherson et al., in their 2018 article published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” a behavior, also called an operant, is modified via consequences. A behavior is likely to be repeated or increased if it is followed by a reward or a reinforcer. On the other hand, removing or withholding the reinforcer leads to a reduction in undesirable behavior. This is an instance of enforcing negative punishment. Positive reinforcement and negative punishment are examples of behavioral consequences.

Sheila M. Alessi in the chapter titled “Contingency Management” of the book Interventions for Addiction published in 2013 describes the process of contingency management. A desired behavior is identified. It is then defined objectively by specifying the evidence that proves the patient has demonstrated the target behavior.

For instance, the identified target behavior is abstinence. A negative toxicology screening, such as a drug-free urinalysis, is the objective evidence that proves the patient has not used drugs. The report determines whether the patient is rewarded with a reinforcer or the reinforcer is withheld. The patient is monitored at specific and frequent intervals to maximize the opportunities for reinforcement and minimize the chances that an undesired, competing behavior, such as using drugs, goes undetected. When the patient demonstrates the target behavior, they are rewarded with the reinforcer. The reinforcer is withheld if they fail to demonstrate the behavior. Reinforcers include vouchers, prizes, special privileges that support recovery, and cash. The type and magnitude of the reinforcer are determined in advance.

Is contingency management effective in treating addiction?

A man in yellow hoodie with a therapist.

Yes, contingency management is effective in treating addiction by enhancing therapy retention, improving adherence to medications, reducing substance use, increasing participation in pro-recovery activities like attending counseling sessions, and sustaining abstinence in varied patient populations, including people with co-occurring mental illnesses, individuals who are homeless, incarcerated individuals, and ethnically and socio-economically diverse groups of people.

In a 2011 article in the journal The Psychiatrist, titled “Contingency management: what it is and why psychiatrists should want to use it,” author Nancy M. Petry refers to several studies that found that contingency management is effective in reducing abuse of alcohol, marijuana, and benzodiazepines, and sustaining abstinence. These studies were carried out on individuals of varied demographics and across different clinical settings, such as methadone management clinics and detoxification centers. The treatment approach is also effective in reducing the abuse of opioids, stimulants like cocaine and methamphetamine, and nicotine or tobacco.

This release by the U.S. Department of Health and Human Services on 7 November 2023, titled “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention” suggests that contingency management is more effective in treating addiction if it is combined with other evidence-based treatment protocols, such as medications, cognitive-behavioral therapy, and the community reinforcement approach, and recovery support services.

For instance, the MOUD (Medications for Opioid Use Disorder) approach is approved by the FDA (Food and Drug Administration) as the gold standard for treating substance abuse involving opioids. Contingency management must not be regarded as a replacement for MOUD or delivered as a first-line intervention in opioid use disorders. Studies conducted over 30 years show that contingency management used adjunctly with MOUD therapy produced more positive and long-lasting effects than standard care in people with opioid use disorders.

How does contingency management work in addiction treatment?

A woman meditating with her hands up.

Contingency management works in addiction treatment at the neurobiological level by modifying specific aspects of addiction pathology, such as disruption of the brain’s reward circuitry and decision-making processes, according to this release by the U.S. Department of Health and Human Services on 7 November 2023, titled “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention.” The reward circuitry in the brain is involved in the learning or maintenance of behaviors that generate rewards, such as feelings of pleasure. The reward circuitry system continuously reinforces the immediate positive and euphoric feelings from substance use. So, the individual feels more motivated to seek out these addictive substances.

Additionally, as the addiction progresses, the addictive substances create imbalances in neural systems, such as the prefrontal cortex, and change the way they work. The prefrontal cortex is involved in the self-regulation and decision-making systems. These systems help individuals evaluate risks and rewards and make decisions like avoiding risky behaviors, resisting temptation, and postponing gratification.

According to this 2018 article by McPherson et al., published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” chronic substance abuse makes the amygdala hyperactive and override the workings of the prefrontal cortex so that the individual is motivated to seek instant gratification from drugs and/or alcohol instead of waiting for the reinforcer.

Contingency management is believed to repair the dysfunctional neural systems in addicted individuals by providing immediate positive reinforcement or desirable, concrete incentives for pro-recovery activities that compete with and replace the reinforcement associated with substance use. The brain is thus re-oriented toward alternative non-substance rewards. During the process, the patient’s decision-making circuits are engaged. So, they are better able to envision the desirability of the non-substance reinforcer and plan and look forward to receiving it. Abstinence targeted by contingency management helps to heal the brain.

According to a release by the U.S. Department of Health and Human Services on 7 November 2023, several studies have shown that people who abuse stimulants like cocaine have damaged gray matter and impaired activity in their reward and self-regulation systems. When they abstain from drugs for an extended period, their brain heals. There is a certain amount of recovery of gray matter tissue and improved activity in the brain’s reward circuitry. These improvements promote sustained abstinence by helping individuals reorient their preferences when seeking pleasure and choosing non-drug alternatives. Contingency management tangentially supports addiction treatment by improving the patient’s interpersonal relationships and employment status.

What interventions are used in contingency management for treating addiction?

A man consoling a woman in therapy session.

The interventions used in contingency management for treating addiction are listed below.

  • Periodically testing for target behavior: In the context of addiction treatment, urine samples are collected several times every week to detect periods of abstinence. According to this 1999 article by Stephen T. Higgins and Nancy M. Petry, titled “Contingency Management: Incentives for Sobriety,” published in the journal Alcohol Research & Health, most toxicology tests are able to detect the presence of drugs in urine samples over a 2-3 day period. So, monitoring for drug use twice or thrice weekly usually suffices. However, breath alcohol tests are able to confirm alcohol use only if the substance was consumed within the past 4-12 hours. Urine and blood tests for alcohol are not much more sensitive compared to breath tests. So, the frequency of testing has to be decided cautiously. The goal is to firstly, encourage the patient to keep up with their good behavior by maximizing the chances of receiving reinforcements and secondly, to minimize the chances that an undesirable behavior goes undetected, according to Sheila M. Alessi in the chapter titled “Contingency Management” of the book Interventions for Addiction published in 2013.
  • Providing positive reinforcement: According to this 2011 article by Nancy M. Petry published in the journal The Psychiatrist, titled “Contingency management: what it is and why psychiatrists should want to use it,” the premise of contingency management is that a desirable behavior that is positively reinforced immediately after it has been displayed is repeated in greater frequency. So, providing positive reinforcement is the cornerstone of contingency management. Generally, monetary-based reinforcers, such as cash, prizes, and vouchers that are exchangeable for retail goods and services, are awarded to patients after they exhibit the target therapy-related behavior.
  • Providing monetary-based reinforcers: According to Jennifer Rothfleisch et al., in the 1999 article titled “Use of Monetary Reinforcers by Cocaine-Dependent Outpatients” published in the Journal of Substance Abuse Treatment, monetary reinforcers have proven to be extremely effective as contingency incentives in the treatment of addiction. However, there is widespread hesitancy in providing money as an incentive given the perception that drug users will likely use the monetary reinforcer to acquire more drugs. In the light of this situation, voucher-based reinforcement (VBR) and prize incentives have emerged as viable reinforcement alternatives to cash. According to this June 2020 publication featured in the Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) by the National Institute on Drug Abuse, titled “Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine),” VBR has proven to be effective in opioids and cocaine users undergoing methadone therapy.
  • Increasing the magnitude of the reinforcer: According to John M. Roll in the section titled “Laboratory Studies” of the chapter Contextual Factors in Addiction from the book “Principles of Addiction” published in 2013, the magnitude of reinforcement is a critical determinant of drug-using behavior. The author mentions a study where recreational cocaine users were recruited to test the above hypothesis. The participants had to choose between doses of cocaine and money, the latter being the alternative reinforcer. It was found that when the monetary reinforcement was low, at $.05, the participants almost always chose cocaine. When the monetary amount was increased to $1.00, only half of the participants chose cocaine. When the monetary amount was further increased to $2.00, the choice was mostly money. These results were replicated in a study involving patients with methamphetamine use disorder.
  • Providing employment-based reinforcement: According to this 2012 article by Silverman et al., published in the journal Preventive Medicine, titled “Maintenance of reinforcement to address the chronic nature of drug addiction,” relapsing after abstinence reinforcements are stopped is common. The authors note that employment-based reinforcement has shown promise in initiating and maintaining abstinence and hence, has the potential to satisfactorily tackle the problem of relapsing after monetary-based reinforcements are discontinued.
  • Withholding reinforcement: According to this 2018 article by McPherson et al., published in the journal Substance Abuse and Rehabilitation, titled “A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies,” withholding reinforcers when the patient does not display the desired behavior is a widely-used intervention method in contingency management. Authors Ledgerwood et al., in their 2008 article published in the Journal of Applied Behavior Analysis, titled “Contingency Management for Attendance to Group Substance Abuse Treatment Administered by Clinicians in Community Clinics,” mention that in several instances of contingency management interventions, reinforcers are withheld and the magnitude is reverted to the initial value. However, there must be consistency in the process, and positive reinforcement must be provided immediately when the desired behavior is exhibited the next time. It must be noted that withholding reinforcement often causes the patient to initially revert to the undesirable behavior before showing conformity and compliance. So, patience needs to be exercised.
  • Targeting abstinence directly: Abstinence reinforcement is an extremely effective way of treating drug addiction, according to this 2020 article by Toegel et al., published in the Journal of Applied Behavior Analysis, titled “Effects of Time-Based Administration of Abstinence Reinforcement Targeting Opiate and Cocaine Use.” Authors Petry et al., in their 2006 article published in the Journal of Consulting and Clinical Psychology titled “Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities.” refer to a study that compared the relative effectiveness of reinforcing abstinence and reinforcing adherence to treatment goals on a sample of substance-abusing outpatients. Abstinence was targeted directly by having the participants submit negative urine toxicology screens at specified intervals. It was found that the participants of the former group whose therapy was based on abstinence reinforcement achieved a longer duration of abstinence during treatment than those in the group that was required to complete goal-related activities. However, abstinence reinforcement procedures are not as significantly effective in treating cases of polydrug use (Toegel et al., 2020).
  • Targeting multiple clinical behaviors relevant to therapy goals: Sheila M. Alessi (2013) suggests that contingency management has further potential for supporting addiction treatment by encouraging therapy-relevant clinical behaviors other than abstinence. These behaviors include adhering to medication, attending counseling sessions, and completing various tasks related to therapy goals. This approach triggers a powerful synergistic effect that manifests quicker and more lasting results than incentivizing one behavior alone.
  • Enlisting those who surround the patient to enforce consequences: Although contingency management usually involves the patient themselves, authors Christopher A. Kearney and Jennifer Vecchio in the chapter titled “Contingency Management” of the Encyclopedia of Psychotherapy published in 2002 mention that mental healthcare practitioners also enlist the support of those who surround the patient to distribute consequences. These include the patient’s family members, those who live with them, their friends, and their employers.

What is an example of contingency management for addiction treatment?

An example of contingency management for addiction treatment is the contingency management programs run by the U.S. Department of Veterans Affairs (VA). According to this release by the U.S. Department of Health and Human Services on 7 November 2023, titled “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention,” the VA started providing contingency management as one of their evidence-based addiction treatment modalities from 2011. It is a nationwide initiative, and treatment is provided via VA medical centers. The VA offers two variations of the contingency management program. Most programs offer abstinence as the target behavior. A few programs offer treatment attendance as an incentivized behavior.

The veterans enrolled in the abstinence program have to provide a negative or drug-free urinalysis report. Those enrolled in the treatment attendance program receive rewards for attending a therapy session. In the abstinence program, the veterans draw from a prize bowl immediately after they provide a negative drug report. The slips include non-winning prizes like simple notes saying “Good job!” and coupons that range in value from $1 to $100. These coupons are exchangeable for goods at Veterans Canteen Service retail stores, coffee shops, and cafeterias.

The white paper titled “Contingency Management for Supporting Substance Use Treatment and Recovery: An Innovative Practice in VHA Homeless Program Operations,” developed by the VHA National Homeless Program Office and published on the website of the U.S. Department of Veterans Affairs describes how the treatment attendance program works. Whenever a veteran completes a week of group attendance, their name is written on a slip of paper and placed in a hat.

So, if a veteran attends five consecutive group meetings, there are five slips of paper with their name on them in the hat. An unexcused absence results in their slip count reverting to one. At the start or end of a session, a certain number of slips are drawn from the hat. The veterans whose names are drawn from the hat are allowed to draw from the prize bowl. The contingency management programs implemented by the VA have recorded high levels of abstinence and increased treatment attendance in the participants.

What types of rewards are used in contingency management for addiction treatment?

A woman in white jacket in a therapy session.

The types of rewards used in contingency management for addiction treatment are listed below.

  • Vouchers: According to this 2014 article by Festinger et al., published in the Journal of Substance Abuse Treatment, titled “Contingency Management for Cocaine Treatment: Cash vs. Vouchers,“voucher-based reinforcement therapy (VBRT) is the most popular form of contingency management in the context of addiction treatment. Vouchers represent a monetary amount but do not entail handing cash to the patient. They are given to patients to buy retail goods, such as food or movie passes, or special-need items specified by the patient. According to this 2005 entry authored by Bartholomew et al., titled “Contingency Management Strategy and Ideas,” and included in the National Registry of Evidence-based Programs and Practices (NREPP), published by the Substance Abuse and Mental Health Services Administration (SAMHSA), in one clinical setting, the items were bought by the personnel at the clinic. Patients also have the option to use the vouchers to acquire goods or engage in activities that support a substance-free lifestyle that promotes sustained abstinence, according to authors Davis et al., in the section titled “Contingency Management” in the chapter Learning Principles in CBT of the 2017 book The Science of Cognitive Behavioral Therapy. Over time, the value of the voucher increases each time the patient reaches a specific target. Authors Adams et al., in their 2012 article titled “Contingency Management for Patients with Cooccurring Disorders: Evaluation of a Case Study and Recommendations for Practitioners” published in the journal Case Reports in Psychiatryrefer to programs where the voucher amount was reset to the original value every time the patient failed to reach a target goal.
  • Prizes: Bartholomew et al., (2005) refer to a study on contingency management to reinforce abstinence where prizes range in value from $1 to $100. Small prizes include candy bars and food coupons worth $1. Medium prizes include books, movie passes, restaurant gift certificates, and backpacks worth about $20. Christine Gella in the section titled Contingency Management of the chapter “Gender-Specific Treatments for Substance Use Disorders” in the 2013 book Interventions for Addiction mentions that gender differences in contingency management outcomes are possible. So, several programs have adopted interventions developed specifically for women. The author refers to drug abuse treatment programs for pregnant women who abuse alcohol or cocaine where the participants were given prizes like children’s items, household goods, and personal hygiene products.
  • Privileges: The patient is rewarded with access to special privileges, such as prime parking spots at the rehab facility, preferred times for appointments, the first choice of methadone dosing hours, and access to a computer. In their 2009 article titled “Employment-Based Abstinence Reinforcement as a Maintenance Intervention for the Treatment of Cocaine Dependence: A Randomized Controlled Trial” published in the journal Addiction, authors DeFulio et al., refer to a study where the participants received access to employment if they provided drug-free urine samples. The access was revoked and pay was reduced if they were unable to provide drug-free samples. Milby et al., in their 2000 article titled “Initiating abstinence in cocaine abusing dually diagnosed homeless persons” published in the journal Drug and Alcohol Dependence refer to a study on a sample of cocaine-abusing homeless individuals where the participants were given access to work and housing opportunities contingent to them reaching a target abstinence goal.
  • Words of praise: Bartholomew et al., (2005)describe the “Fishbowl Method” developed by Nancy Petry where written praise is used as positive reinforcement. The participants in a study who attained specified target abstinence goals earned the right to draw slips of paper from a prize bowl and win prizes worth the value written on the paper. About a quarter of the slips in the bowls contained encouraging words like “Good job!” Although a non-winning prize, written praise is a powerful social reinforcer for a demographic habituated to being criticized, shamed, and made to feel guilty for their addiction issues.
  • Cash: According to Festinger et al., (2014), research indicates that cash is a more powerful reinforcer than vouchers because it is perceived to be more valuable than vouchers of the same amount. According to this 2011 article by Sadie F. Dingfelder published in Monitor on Psychology, a magazine by the American Psychological Association, titled “Will behave for money,” many contingency management programs use cash as a reinforcer.