Contingency management (CM) is the application of the three-term contingency (or

operant conditioning Operant conditioning, also called instrumental conditioning, is a learning process where behaviors are modified through the association of stimuli with reinforcement or punishment. In it, operants—behaviors that affect one's environment—are c ...

), which uses stimulus control and consequences to change behavior. CM originally derived from the science of

applied behavior analysis Applied behavior analysis (ABA), also called behavioral engineering, is a psychological intervention that applies empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance.S ...

(ABA), but it is sometimes implemented from a

cognitive-behavior therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (su ...

(CBT) framework as well (such as in dialectical behavior therapy, or DBT). Incentive-based contingency management is well-established when used as a clinical behavior analysis (CBA) treatment for

substance use disorder Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences as a result of their use. Substance use disorders are characterized by an array of mental/emotional, physical, and ...

s, which entails that patients' earn money (

voucher A voucher is a bond of the redeemable transaction type which is worth a certain monetary value and which may be spent only for specific reasons or on specific goods. Examples include housing, travel, and food vouchers. The term voucher is als ...

s) or other incentives (i.e., prizes) as a reward to reinforce drug abstinence (and, less often, punishment if they fail to adhere to program rules and regulations or their treatment plan). Another popular approach based on CM for

alcoholism Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomi ...

is the

community reinforcement approach and family training Community reinforcement approach and family training (CRAFT) is a behavior therapy approach in psychotherapy for treating addiction developed by Robert J. Meyers in the late 1970s. Meyers worked with Nathan Azrin in the early 1970s whilst he was de ...

(CRAFT) model, which uses self-management and shaping techniques. By most evaluations, its procedures produce one of the largest effect sizes out of all mental health and educational interventions.

Token economies

One form of contingency management is the

token economy A token economy is a system of contingency management based on the systematic reinforcement of target behavior. The reinforcers are symbols or tokens that can be exchanged for other reinforcers. A token economy is based on the principles of op ...

system. Token systems can be used in an individual or group format. Token systems are successful with a diverse array of populations including those suffering from addiction, those with special needs, and those experiencing delinquency. However, recent research questions the use of token systems with very young children. The exception to the last would be the treatment of stuttering. The goal of such systems is to gradually thin out and to help the person begin to access the natural community of reinforcement (the reinforcement typically received in the world for performing the behavior). Walker (1990) presents an overview of token systems and combining such procedures with other interventions in the classroom. He relates the comprehensiveness of token systems to the child's level of difficulty.

Voucher programs and related applications in addiction treatment

Another form of contingency management is voucher programs. In voucher-based contingency management patients earn vouchers exchangeable for retail items contingent upon objectively verified abstinence from recent drug use or compliance with other behavior-change targets. This particular form of contingency management was introduced in the early 1990s as a treatment for cocaine dependence. The approach is the most reliably effective method for producing cocaine abstinence in controlled clinical trials. Medication take-home privileges is another form of contingency management frequently used in methadone maintenance treatment. Patients are permitted to "earn" take-home doses of their methadone in exchange for increasing, decreasing, or ceasing certain behaviors. For example, a patient may be given one take-home dose per week after submitting negative drug screens (generally via urine testing) for three months. (It is worth noting that take-home-doses (or "bottles") are seen as desirable rewards because they allow patients to come to the clinic less often to obtain their medication). Based on

(ABA), contingency management includes techniques such as choice and preference assessments, shaping, making contracts between the therapist and patient,

, and

. Contingent vouchers are also used to cease smoking addictions. One study claims that people with substance use disorders can receive help with their addiction through the use of voucher-based treatment for smoking. In addition, nicotine replacement (NRT) can help with addiction combined with the vouchers.

Level systems

Level systems are often employed as a form of contingency management system. Level systems are designed such that once one level is achieved, then the person earns all the privileges for that level and the levels lower than it.

Effectiveness in addiction programs

meta-analysis A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting m ...

of contingency management in drug programs showed that it has a large effect. These contingencies are delivered based on abstinence and attendance goals and can take the form of vouchers, the opportunity to win prizes or privileges. They have been used with single problem addictions as well as dual diagnoses and homelessness. Overall contingency management is an effective and cost-efficient addition to drug treatment.Olmstead TA, Sindelar JL, Petry NM. (2007). Clinic variation in the cost-effectiveness of contingency management. ''Am J Addict.'', 16 (6), 457–60 In contrast to these findings in a recent study, the researchers found out that nicotine replacement treatment only improved the effects of contingent vouchers on short-term smoking abstinence. However, in the long term, the effects of contingent vouchers had no impact on tobacco resistance.

Organizations

Many organizations exists for board certified behavior analysts using contingency management around the world.

References