Contingency management: what it is and why psychiatrists should want to use it (2024)

Abstract

Contingency management is a highly effective treatment for substance useand related disorders. However, few psychiatrists are familiar with thisintervention or its application to a range of patient behaviours. This paperdescribes contingency management and evidence of its efficacy for reducingdrug use. It then details areas in which contingency management interventionscan be applied in the context of psychiatric treatments more generally,including increasing abstinence in individuals with dual diagnoses,encouraging attendance in mental health treatment settings, enhancingadherence to psychiatric medications, reducing weight, and improving exercise.Greater awareness and use of contingency management in practice may improveoutcomes across a range of mental health and related conditions.

Contingency management refers to a type of behavioural therapy in whichindividuals are ‘reinforced’, or rewarded, for evidence ofpositive behavioural change. These interventions have been widely tested andevaluated in the context of substance misuse treatment, and they most ofteninvolve provision of monetary-based reinforcers for submission ofdrug-negative urine specimens. The reinforcers typically consist of vouchersexchangeable for retail goods and services or the opportunity to win prizes.Although contingency management has a great deal of evidence supporting itsefficacy,¹ and theUK National Institute for Health and Clinical Excellence guidelines recommendits use, few psychiatrists and other mental health professionals are familiarwith these interventions, and even fewer implement contingency management intheir practice.

Contingency management principles

Contingency management interventions are based on principles of basicbehavioural analysis. A behaviour that is reinforced in close temporalproximity to its occurrence will increase in frequency. Thus, if you give achild a small toy or sticker each time he makes his bed, the child will startmaking his bed more often. Behavioural principles of positive reinforcementare widely applied in everyday settings (childrearing, employment, pettraining), as well as clinical settings (autism, conduct disorder inadolescents, intellectual disability).

These behavioural principles can also be applied to treat substance usedisorders. In contingency management interventions for substance misusetreatment, urine samples are collected multiple times each week (to detectbrief periods of abstinence) and abstinence is reinforced each time negativesamples are submitted. The reinforcers are monetary based and consist ofvouchers, analogous to a clinic-managed bankaccount,² or a prizedraw with prizes ranging from US$1 to 100 invalue.³ Importantly,in effective contingency management interventions, the magnitude ofreinforcement provided (voucher amounts or draws for prizes) increases withsustained periods ofabstinence.^2,3

Evidence base

A vast amount of empirical evidence indicates the efficacy of contingencymanagement for treating substance use disorders. For example, in multicentrestudies conducted throughout theUSA,^3,4over 800 individuals with stimulant misuse from 14 clinics were randomlyassigned to standard care as usual plus twice-weekly urine sample testing, orthat same treatment plus contingency management for 12 weeks. In thecontingency management group, individuals earned at least one draw with achance of winning a prize ranging from US$1 to 100 in value for eachstimulant-negative sample submitted, and number of draws earned increased withweeks of consecutive abstinence. About half of the sample were recruited frompsychosocial (non-methadone) and half from methadone clinics. In thepsychosocialclinics,³contingency management significantly enhanced retention in treatment, with 49%of the contingency management group completing 12 weeks of treatmentv. only 35% the of standard care group. The mean number of weeks ofconsecutive abstinence from stimulants was 4.4 for those assigned tocontingency management v. 2.6 for those assigned to standard care.The percentage of individuals who sustained stimulant abstinence throughoutthe full 12 weeks was nearly 4 times greater for the contingency managementcondition (18.7% v. 4.9%). In the methadone arm of thestudy,⁴ durations ofcontinuous cocaine abstinence achieved were also significantly enhanced in thecontingency management condition relative to the standard care condition, withmeans of 2.8 v. 1.2 weeks of abstinence respectively. Again, thecontingency management group were significantly more likely to maintaincontinuous abstinence throughout the 12-week study period than the standardcare group (5.6% v. 0.5%).

Similar beneficial results of contingency management have been reportedwith respect to decreasing other forms of substance use. It is efficacious inreducing opioid use, whether individuals are maintained on a substitutionmedication such asmethadone⁴ orundergoing opioiddetoxification.¹Contingency management also reduces the use of alcohol, marijuana andbenzodiazepines.¹Even among those who smoke cigarettes and do not wish to stop, contingencymanagement can substantially decreasesmoking.¹Meta-analyses of contingency management interventions find that it isefficacious across a range of populations andsettings.¹ Ameta-analysis of psychosocial treatments for substance use disorders revealsthat contingency management is the intervention with the greatest effectsize.⁵

Barriers to implementation

Despite its established efficacy, contingency management is the empiricallyvalidated treatment with which clinicians are least familiar. Surveys ofmental health providers in theUSA⁶ and othercountries⁷ revealthat few are aware of this intervention, and even fewer use it in practice.Reasons for the lack of use range from little formal training or coursework inbehaviour analysis generally or contingency management specifically,ideological concerns, disconnect between research and practice, and costs.Each of these barriers can be overcome, and introduction of contingencymanagement techniques into substance misuse treatment and psychiatric practicemore broadly can have a positive impact on patients, providers, and perhapseven society at large.

Applicability to other settings

One area in which contingency management has widespread potential benefitsis individual retention in treatment. Psychiatric treatments suffer from highrates of attrition, which in turn relates to increased morbidity andmortality. Substance misuse treatment clinics typically experience attritionrates of 80% or higher, and attrition is high in most other out-patient mentalhealth treatment as well. By providing reinforcement contingent on attendance,attendance rates across a range of treatment settings can be substantiallyimproved,^1-3thereby increasing exposure to effective care.

Contingency management is not only useful for enhancing retention intreatment and decreasing drug use in primary substance misusetreatment-seeking samples, but also for individuals with dual diagnosis, inwhom rates of substance use disorders are disproportionately high. Severalstudies now point to the effectiveness of contingency management for reducingcocaine and marijuana use in people with psychoticdisorders.⁸Extraordinarily high rates of smoking are noted in individuals withschizophrenia and contingency management holds promise for decreasing smokingin this grouptoo.⁹

Another application for contingency management highly relevant topsychiatrists relates to reinforcing adherence to medications. Provision ofreinforcement for direct supervised ingestion of medications has provensuccessful in somepopulations.¹⁰ Suchprocedures may be particularly useful for psychiatric patients with low levelsof adherence to some medications. Other options that do not require directsupervision of medication ingestion include reinforcing MEMS (MedicationEvents Monitoring System) cap openings, an approach that has been successfulin increasing adherence to antiretroviral medications in individuals withHIV.¹⁰

Two additional applications of contingency management are relevant topsychiatry. The intervention appears to be useful in assisting individuals tolose weight.¹¹Given high comorbidity between overweight/obesity and psychiatric disorders,contingency management for weight loss may be advantageous in psychiatricpatients with obesity. On a related note, contingency management appearseffective in increasing adherence to exerciseregimens.¹² Giventhe inverse association between regular exercise and depressive symptoms,reinforcing individuals for objective evidence of initiating and maintainingexercise routines may have positive benefits with respect to mental health aswell as physical health outcomes.

Advantages to healthcare providers

Not only do patients stand to gain by the introduction of contingencymanagement but so do providers. A positive report comes from the introductionof contingency management into standard practice in substance misuse treatmentprogrammes in NewYork.¹³ Asindividuals were reinforced for attending groups, group sizes and participantmorale increased, along with provider morale. Lott &Jencius¹⁴ foundthat reimbursem*nt rates substantially increased when contingency managementwas introduced to adolescents who misused substances.

Cost concerns remain paramount regarding the use of contingency management,and research reveals that efficacy is reduced if reinforcement magnitude istoo low.¹ However,evaluations of new methods of reinforcement show that costs can be minimisedand beneficial effects stillremain.¹⁵ Further,cost-effectiveness analyses of contingency management find that sometimesincreasing the upfront magnitude of reinforcement can result in greatercost-effectiveness with respect to patientoutcomes.¹⁶

Clinics in Spain, Canada and the USA have reported that some or most of thereinforcers for contingency management can be obtained via communitydonations.¹⁷ Theseapproaches may be particularly advantageous with respect to raising funds forhighly vulnerable populations, such as pregnant women, adolescents, peoplewith HIV, homeless individuals, and those with severe and persistent mentalhealth disorders.

In sum, contingency management interventions have substantive evidence ofefficacy in positively modifying a variety of patient behaviours, andadaptations of these techniques to a variety of problem behaviours may furtherincrease their relevance and widespread use. Eventually, greater understandingand awareness of contingency management may assist in bringing thisempirically based intervention into a variety of psychiatric settings andspecialty areas.

Funding

Preparation of this report is based in part on NationalInstitutes of Health grantsP30-DA023918;, R01-DA027615;,R01-DA022739;, RO1-DA13444;,R01-DA018883;, R01-DA016855;,R01-DA14618;, P50-DA09241;,P60-AA03510;, R01-DA024667, andGeneral Clinical Research Center grantM01-RR06192.

Notes

Declaration of interest None.

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