I fucking love Contingency Management (CM). It is one of the fastest ways to throw a wrench into the works of hyperindividualistic broken-brain models that discourage psychosocial analyses that would lead to systemic critiques and calls for reform.
Overview
Over three decades of research into contingency management interventions has shown that it routinely outperforms Cognitive-Behavioral Therapy and 12-step facilitation models. It is the gold standard for stimulant use disorders, which have no FDA-approved medications. Adding CM to Medication for Opioid Use Disorder (MOUD) protocols substantially improves cigarette use, medication adherence, illicit opioid use, polysubstance use, and therapy attendance. Even after the external rewards stop, those who completed a contingency management program were significantly more likely to maintain long-term abstinence.
Types
By Reinforcement
Voucher-Based Reinforcement
Stephen Higgins pioneeered this model by awarding points or vouchers for passing drug tests, with each voucher having monetary value that can be used to buy groceries or other goods.
Prize-Based CM (Fishbowl Method)
Nancy Petry designed a stochastic method of contingency mangement that could lower costs: instead of a guaranteed voucher for a set amount, participants who pass a drug test can draw a slip from a bowl that contains anything from encouraging words to a substantial prize (up to $100).
Financial Incentives
These methods cut to the chase and directly exchange money for clean drug tests without constraints on how it’s used.
Clinical Privileges
Found largely in Opioid Treatment Programs (OTPs) where medications like buprenorphine and methadone exist, these systems give patients more liberty for consistent behavior like doses to take-home as a sign of trust and convenience.
Therapeutic Workplace
Developed by Kenneth Silverman at John Hopkins University, therapeutic workplace programs are evidence-based interventions that provide training and employment as an incentive to maintain sobriety.
Yes, people will literally stay sober if you promise to guide them into a job. Just like people will commit fewer crimes if they have stable employment and housing. Just like people will report a higher quality of life when they don’t have chronic stress building from financial instability.
This is one of the only interventions I’ve found that have incredibly strong empirical support for long-term sobriety and quality of life improvements that addresses the psychosocial causes of substance use, which is alarming since we claim to now work through a biopsychosocial model of health yet completely overlook this in favor of expanding manualized therapies that are less effective.
I’ll put it this way: I have been in psychoeducation classes that consisted entirely of YouTube videos featuring TedTalks and sound bowl ASMR, with facilitators saying, quote, “I get paid either way” if clients say don’t see it as valuable or if one client derails an entire session. We’re not talking minimum wage jobs either; they have proudly quoted $35/hr with free daily meals. This is the same formula as a substitute teacher turning on Bill Nye the Science Guy and turning a blind eye to everyone being on their smartphones. This class might then be followed by one about projection, so that if you did have any feedback about the process, you can learn about how the real problem is you being judgmental to deflect from your own insecurities. Or it might be a class about taking responsibility, though not if it leads you to feeling responsible enough for your recovery that you would try to adjust the treatment you’re receiving. If you really keep pushing as I once did, you’ll get told that you should leave it to professionals since your own judgment got you to where you are, which completely tosses out our biopsychosocial premises in favor of a Puritan moral-psychology that elevates obedience and confession to authority over humanist ideas of treating people as the center their own lived realities.
That exact same hourly wage could have been allocated to helping some of these clients with their career goals. Many have expressed a desire to become peer counselors who can use their own trauma and recovery as experience to guide others, which seems to me far preferable to paying babysitters who will literally use an ASMR stream to get paid while napping.
By Target Behavior
Abstinence-Based
Most contingency management programs aim to test sustained abstinence with urine testing or breathalyzer screenings.
Attendance/Adherence-Based
Some models experiment with rewarding patients for participating in treatment, such as showing up for therapy sessions and taking medications as prescribed, regardless of their drug use.
Goal-Directed CM
Because every individual has their own goals from not just recovery but life in general, these models set up rewards or incentives for completing long-term goals tailored to someone’s specific circumstances, like building a resume or submitting applications for housing.
By Format
Digital CM
Modern devices make it much easier to deliver contingency management programs without requiring visits to a clinic. Remote testing devices and digital cards mean that we can both instantly validate someone’s drug or treatment status and instantly reward them upon completion.
Variable Ratio Schedules
Variable scheduling changes some aspect of reward delivery with respect to time. For instance, if someone has maintained a streak of hitting their goals, the value of the reward might increase as well. If the streak is broken, the reward schedule might reset to square one.