Contingency Management Treatment
Addiction can be a difficult cycle to break. Even when an individual is committed to attaining sobriety, overcoming cravings and powerful withdrawal symptoms can make the end goal feel impossibly unattainable at times.
For some, the process of overcoming their addiction benefits from ongoing reinforcement for smaller, though still significant, goals. At its core, this is the principle behind the implementation of Contingency Management for Addiction.
Contingency Management is a process in which those overcoming addiction receive physical low-value rewards for making continuous positive change. Those that advocate for Contingency Management understand the value of achievable, tangible rewards when up against a force as daunting and vague as addiction.
Vouchers to be traded in, small-cash rewards, and random drawing entries are examples of such low-value rewards that can, alongside ongoing counselling and medicating, support individuals as they work towards sobriety. While not a solution to addiction on its own, research suggests that Contingency Management can be particularly effective in overcoming dependency in those using opioids, cocaine, heroin, and potentially even alcohol.
History of Contingency Management
Contingency Management in the treatment of addiction has roots dating back to early behaviourism thought during the mid-1900’s. Scientists such as B.F. Skinner and Ivan Pavlov become major figures in the field of psychology for their work in this field, and relics such of the innovative Skinner Box and Pavlov’s infamous bell-ringing study remain popular examples of the potential for operant conditioning in shaping behaviour.
As researchers of the time posited, the association of positive emotions with a physical stimulus has the potential to shape the animal (and human) mind, resulting in new learned behaviours with withstand the test of time.
The application of Contingency Management specifically in the treatment of addiction is a newer field of study, and while research from throughout the 21st century has suggested that the process is beneficial for seeking sobriety, the consensus remains that more testing is needed on the subject.
What data that has been made available demonstrates Contingency Management supports favourable outcomes for those working towards sobriety. However, with the relative novelty of this line of research, it is impossible to extrapolate results to every individual facing addiction, and the practice should continue to be practiced in conjunction with traditional therapies and medication.
Theory Behind Contingency Management
Sobriety is not a single action, but the culmination of numerous positive choices that an individual makes. While in strong moments, a person might be able to resist relapsing, effective treatment of addiction should aim to make healthy choices so natural that they become standard even on bad days and in those weaker moments we all experience.
While at the beginning of treatment, a person might make specific choices simply for the promise of low value but desirable rewards, the aim in Contingency Management is to associate the positive emotion of being rewards with the good decision over the reward. In the long term, this will result in healthy choices being the natural choice and a positive state should ensue, even after the period for receiving a reward has passed.
This process of operant conditioning is demonstrated well by the famous example of Pavlov training his dogs to salivate. As history tells, Pavlov would feed his dogs every day after ringing a distinctive bell.
Over time, the dogs became so acclimated to this procedure that, by the end of his research, the act alone of ringing the bell would cause the dogs to salivate – even if no food was present. And while the canine and human minds are distinctive, this process of learning occurs in human beings in much the same way (see the case of Little Albert for one such human example, if interested).
An individual does not need to be rewarded for making positive, healthy, sober choices forever for Contingency Management to be successful. As beneficial behaviours become mentally tied to the joy of being rewarded, the action alone should ultimately be enough to trigger the response, just like with Pavlov and his salivating dogs.
The person will begin to naturally make desirable decisions because their body has come to associate sobriety with pleasure rather than the drug in question. In this way, Contingency Management promotes sustainable sobriety for many patients struggling with drug and/or alcohol dependency.
The Use of Contingency Management for Addiction Treatment
Research on Contingency Management has suggested a benefit to offering rewards for healthy, desirable behaviours in those suffering from addiction. The reward can be offered by doctors, counsellors, or other medical professionals, or on a more casual basis by friends and family members looking to support their loved on.
For instance, a medical practitioner might enter patients with clean drug screenings in a raffle for a desirable prize, or a friend could offer a present each time the individual attends their counselling session each week. As long as the reward is regularly applied and is a reliable result of completing the action in question, a positive association can be developed between the act and the reward.
Operant conditioning as a theory additionally incorporates the use of punishment in the reinforcement of desired behaviours. However, punishment is not suggested for use within the frame of Contingency Management.
Friends, family, and medical professionals should be weary of associating themselves with pain or suffering as they support the individual working towards sobriety: trust and openness is too intrinsic to the recovery process to risk straining the existing bond through punishment. Professionals suggest those utilising Contingency Management stick primarily to applying positive rewards and turn to punishment only when absolutely necessary.
Who is Most Likely to Benefit from Contingency Management Treatment?
As discussed previously, Contingency Management has been demonstrated to be particularly effective for treating those suffering from addiction to opioids, cocaine, heroin, and/or alcohol. In addition, the process of rewarding positive behaviour is a practice that can be used in the treatment of co-morbid disorders that may or may not contribute to past drug use.
The physical symptoms of mental disorders such as depression, anxiety, and ADHD can often be lessened through the implementation of Contingency Management Treatment and are worth consideration as you or your love one seeks addiction treatment.
7 Principles of Contingency Management
- Identify the Target Behaviour. Before applying any rewards, be sure to sit down and determine specific behaviours that will be targeted during the Contingency Management process. The elimination of past harmful actions or the application of healthier alternatives both make for good targets for treatment. Be sure that everyone involved in treatment are aware of the behaviour selected – because rewards need to be consistent, there should be no ambiguity as to what constitutes “good” behaviour
- Identify the Target. Not every person attempting to overcome addiction will benefit from Contingency Management. If the individual in treatment is motivated without reward or is uninterested in the reward offered, Contingency Management might not be a useful approach towards treatment
- Identify the Reward. Not every reward will appeal to every individual undergoing Contingency Management. The reward offered to a person should be desirable to the target audience, but also needs to be attainable to the administrator. Those involved in the treatment process should work together with one another and with the individual to determine a sensible reward
- Consider Reward Significance and Size. If the individual seeking treatment is offered larger, more costly rewards, administrators will likely need to limit the number of rewards offered. Offering smaller, lower-value rewards allows administrators to provide more regular feedback to the individual in treatment but might not be enough to trigger a positive emotional response. The treatment team needs to balance reward quantity and quality at this point based on past performance by the target individual as well as their own available resources
- Consider Reward Frequency. Settle on a timeline for when rewards will be offered to the individual. Rewards need to be reliable, so planning for regular rewards throughout the duration of treatment is encouraged
- Consider Reward Timing. In order to associate an action with a positive emotion, the reward should be provided to the individual immediately after the desired behaviour emerges. Gaps between a specific behaviour and a reward weakens the connection and can prevent the target’s body from connecting the stimulus to the outcome
- Consider Duration. Ideally, Contingency Management will be a temporary practice that results in permanent behaviour change. Therefore, everyone involved in the treatment of the addiction should consider how long rewards should be on offer. Once an individual’s body has learned to associate healthy choices with positive feelings, Contingency Management can halt. Cancelling treatment too soon, however, risks nulling any learning that has begun to take place
Types of Contingency Management
Two basic forms of Contingency Management have taken shape as research develops. While certainly each can be modified and tailored to fit a specific person’s own needs, the categories listed provide a solid foundation for those looking to design and implement a Contingency Management plan in their treatment of addiction.
- Voucher-Based Reinforcement (VBT) is a system in which vouchers for goods and services are offered to an individual after a specific desired behaviour has taken place. Over time, vouchers are designed to increase in monetary or sentimental value, encouraging a person to remain sober as they work towards more desirable rewards. As the potential reward on offer increases in its worth, the cost of a relapse grows, deterring individuals from giving in to any desire to relapse
- Prize Incentives, alternatively, incorporate an element of randomness in order to excite clients working towards sobriety. In this system, positive action results in the individual being granted the opportunity to randomly select a prize amid a large selection. Because the rewards are uncertain, they will vary in value and desirability. Participants curious about other rewards or eager to earn a better prize will need to continue making a positive change to pick for a new reward in the future
Ultimately, no one plan is objectively better than the other. An individual interested in incorporating Contingency Management into their treatment plan should work with family, friends, and medical professional in order to determine what reward system might make the most sense for their own unique situation given their past history and their approach to pleasure-seeking.
Using Rewards for Healthy and Sober Living
For a person struggling with addiction, drugs and/or alcohol have become the main source of pleasure for the individual. These substances trigger the brain to release chemicals associated with pleasure and rewards, resulting in the high that the individual craves. Over time, as the threshold for the amount of a substance needed to activate this trigger rises, individuals become more dependent upon this substance in order to feel like themselves. It is key then throughout treatment that reward pathways become dependent upon positive, healthy behaviour rather than intoxicating ones.
By rewarding healthy behaviours, an individual’s brain begins to associate these pleasurable chemicals with healthy action rather than the drug of choice. These newly learned behaviours can help a person break dependency permanently, hence the value of activating these chemicals throughout the treatment process. So, while Contingency Management isn’t the only method of triggering pleasure pathways in the brain, it is a reliable way to incorporate learning into addiction treatment
Criticisms of Contingency Management
As a remarkably recent approach towards treating substance abuse, a number of concerns have been raised about Contingency Management. For instance, some researchers point out that reward-based learning can be an expensive process not accessible to every individual suffering from addiction. Others cite concerns that the process, particularly Prize Incentives, might promote gambling without actually addressing underlying issues.
While more research is needed in this field, what is available suggests that Contingency Management is a promising approach to addiction treatment when applied concurrently with more traditional treatment methods. While cost and fears regarding addiction are certainly valid, individuals are able to tailor the procedure to suit their own unique situations and needs.
While Contingency Management might not be the perfect solution for every individual working to manage their addiction, research demonstrates that, when utilised properly, it has the potential to promote healthy living and break harmful cycles that result in relapse.
If you or a loved-one would like to benefit from contingency management techniques, contact Rehab Recovery today on 0800 088 66 86 and we will be happy to recommend treatment providers in your area that offer this type of treatment.