What Is Contingency Management Therapy?
It may seem a tad bit Pavlovian in nature, but contingency management therapy (CMT) actually operates on the basis of a reward system. Positive reinforcement of good behaviors — like staying drug-free and sober during and after substance abuse treatment — encourages ongoing good behavior. In addition, positive reinforcement and rewards are withheld whenever such negative behaviors occur.
Likewise, some treatment programs may also enforce punishment on the participant whenever poor behavior is exhibited. This may be carried out via reporting said behaviors to a parole officer, per Alcohol Research & Health— something that is generally commonplace for those being treated for substance abuse due to judicially mandated treatment requirements, often the result of criminal activity.
At the end of the day, the goal of CMT is to promote the reduction of drug and alcohol use or total abstinence from such while encouraging positive behaviors within society.
According to the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, CMT techniques have grown in recent years to encompass not only efforts to thwart drug use and relapse, but also to improve attendance at treatment programs, compliance with goals, and cooperation with medication regimens. Public Health England’s National Treatment Agency for Substance Misuse states that contingency management, when utilized appropriately with other interventions, can aid in:
- Reducing or ending dependency on drugs
- Involving patients in treatment-geared activities
- Making treatment more appealing to patients via incentives for attending activities
- Bettering the patient’s cooperation with health measures including treatment and prevention efforts
One type of contingency management therapy — voucher-based reinforcement — uses financial incentives in the form of vouchers to encourage drug users to stay clean. The voucher format is necessary because many drug users would use cash to buy drugs. Thus, the voucher can be exchanged in treatment programs for things like movie tickets and food, per the National Institute on Drug Abuse.
It may seem impractical to some that there are people who enter substance abuse treatment but don’t complete it. For those people, it is necessary to understand that not everyone is a willing participant toward substance abuse remediation. Some addicts are forced into treatment by court order; some are pushed into it by family while others do enter on their own but want to jump ship a few weeks into the program. The American Psychological Association accounts for as much as 80 percent of cocaine abusers failing to complete treatment programs. Likewise, the APA discusses decades of research carried out by Dr. Stephen Higgins of the University of Vermont, citing a 2003 research review wherein 15 of 16 studies showed significant results in favor of contingency management therapy and voucher-incentive programs due to their increased effectiveness in keeping recovering cocaine addicts from using.
Another form of contingency management therapy is prize incentive-based and consists of rewarding positive behaviors such as abstinence with prizes instead of exchange vouchers. Little research exists in the way of comparing the efficacy of prize-based CMT to voucher-based, but both show promising results standing alone.
Generally, prizes are not handed out in the same way that vouchers are. The latter are guaranteed upon receipt of clean urine samples, regular attendance and such. Rather, the prize-based CMT method involves more of a contest among participants. Every time a treatment patient has a drug-free urinalysis result, meets attendance or goal standards, and so on, they have their name entered into a prize drawing. Thus, someone who regularly exhibits good behaviors will have their name entered into the drawing more times than someone who doesn’t, giving them a greater chance at having their name picked as the prize winner. Most often, prizes are valued anywhere between $1 and $100.
Who Needs CMT?
Contingency management therapy is commonly used in many drug treatment programs using methadone as a maintenance treatment option for opioid addiction. Drug users aren’t exactly known for their interest in their own well-being. Health care is a common concern among the illicit drug user population. According to HIVandHepatitis.com, over one million people might have hepatitis B worldwide. Alarming statistics like this point to the common trend of vaccination absence among those who are drug abusers or who grow up in a socioeconomic climate that makes drug abuse more likely in adulthood.
A recent article published in The Lancet discusses the high prevalence of hepatitis B among illicit drug injectors and their combined unlikeliness to get vaccinated for such infectious diseases. The UK-based study offered vaccinations to three groups. Those in group one were offered the vaccinations with no incentive. Contingency management comes into play with the other groups wherein participants of the second group were given three £10 vouchers, and those in group three were given incentives on an increasing basis of £5, £10, and £15 vouchers. The goal researchers sought was participant completion of hepatitis B vaccinations within a four-week period. The results were impressive with only a mere nine percent of group one participants reaching the goal while 45 percent of those in group two and 49 percent of group three participants did.
Dual diagnosis patients — those with the presence of more than one disorder — are good candidates for contingency management therapy. Psychosocial counseling treatment programs also utilize CMT for patients in effort to promote cessation and abstinence from drug use, according to the National Institute on Drug Abuse.
One study, discussed in an article published in the American Journal of Psychiatry, produced fantastic success rates with 61 percent of drug addicts undergoing contingency management therapy having successful results and only 39 percent doing such in comparison groups that did not receive CMT.
Controversies Surrounding CMT
One study that was carried out by the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine produced results showing lesser efficacy with only 42 percent of those participating under contingency management controls successfully completing an entire treatment period, in comparison to 65 percent in the control group. However, it is important to note that those undergoing CMT interventions were still 2.4 times more likely to produce negative drug screening results than their control group counterparts. These results are evidence that contingency management therapy may serve to inhibit drug use even when the structure provided by professional care or treatment programs isn’t present or as heavily involved.
WebMD makes an important note of the expensive cost of contingency management therapy. A British Journal of Psychiatry article mentions that voucher-based incentive programs allow for participants to earn up to $1,200 worth of products via vouchers during just 12 weeks of treatment. While a survey by the Treatment Research Institute accounted for 54 percent of the treatment providers questioned being advocates of adding contingency management interventions to their protocol, this rarely happens due to the burdensome costs involved and possible interactions with other treatment regimens.
An article published in the Psychology of Addictive Behaviors also notes the inability to realistically keep up with the ever-increasing costs of voucher-based incentives; while an initial voucher may be for a mere few dollars, continuing the trend forever would be impossible. Likewise, the need for continued incentives in order to remain drug-free is often questioned, as some research points to positive behaviors ending as soon as reinforcements do. Prize-incentive CMT options may be preferable in years to come due to the ability to control costs.
The most common form of therapy used in conjunction with contingency management efforts is Cognitive Behavioral Therapy. The previously mentioned Psychology of Addictive Behaviors article notes that the dual usage of both CBT and CMT during treatment might present certain problems, with CBT lessening the initial effects of CMT in the beginning stages of treatment. However, after treatment, those participants who were treated with the CBT before were more likely to be employed.
The study thoroughly examines the effects of both CMT and CBT individually in the treatment of substance abusers and postulates worthwhile theories regarding the two as a combined therapy effort. Interestingly, the same study also notes that those who underwent CBT were more likely to report cocaine usage than those who did not engage in CBT methods. While not statistically significant, those who were treated with the combined CBT and CMT therapy were more likely to show a gradual but lasting decrease in cocaine use at the post-treatment follow-up point one year later.
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