Contingency management

Contingency management (CM) is the application of the three-term contingency (or operant conditioning), which uses stimulus control and consequences to change behavior. CM originally derived from the science of applied behavior analysis (ABA), but it is sometimes implemented from a cognitive-behavior therapy (CBT) framework as well (such as in dialectical behavior therapy, or DBT).

For use in management theory, see Contingency theory.

Incentive-based contingency management is well-established when used as a clinical behavior analysis (CBA) treatment for substance abuse, which entails that patients' earn money (vouchers) 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 is the community reinforcement approach and family training (CRAFT) model, which uses self-management and shaping techniques.

By most evaluations, its procedures produces one of the largest effect sizes out of all mental health and educational interventions.[1]

Token economies

One form of contingency management is the token economy system.[2] Token systems can be used in an individual or group format.[3] Token systems have been shown to be successful with a diverse array of populations including those suffering from addiction,[4] those with special needs,[5] and those experiencing delinquency.[6] However, recent research questions the use of token systems with very young children.[7] The exception to the last would be the treatment of stuttering.[8] 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).[9]

Walker (1990) presents an overview of token systems and combining such procedures with other interventions in the classroom.[10] He relates the comprehensiveness of token systems to the child's level of difficulty.

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.[11][12] The approach is the most reliably effective method for producing cocaine abstinence in controlled clinical trials.[13][14]

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 applied behavior analysis (ABA), contingency management includes techniques such as choice and preference assessments, shaping, making contracts between the therapist and patient, community reinforcement approach and family training, and token economy.

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.[15]

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.[16]

Effectiveness in addiction programs

A meta-analysis of contingency management in drug programs showed that it has a large effect.[17] These contingencies are delivered based on abstinence and attendance goals[18][19] 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[20][21] and homelessness.[22] Overall contingency management has been found to be an effective and cost efficient addition to drug treatment.[23]

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.[15]

Organizations

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

See also

References
  1. Forness, S.R., Kavale, K.A., Blum, I.M., & Llyod, J.W. (1997). Mage-analysis of meta-analysis: What works in special education and related services? Teaching Exceptional Children, 29, 4–9.
  2. Zlomke, L. (2003). Token Economies. The Behavior Analyst Today, 4 (2), 177–184 BAO
  3. Axelrod, S. (1973) "Comparison of individual and group contingencies in two special classes". Behavior Therapy, 4, 83–90.
  4. Petry, N.M. (2001) Contingent reinforcement for compliance with goal-related activities in HIV-positive substance abusers. The Behavior Analyst Today, 2 (2), 78 BAO
  5. Birnbrauer, J.S., Wolf, M.M., Kidder, J.D., & Tague, C.E. (1965). "Classroom behavior of retarded pupils with token reinforcement". Journal of Experimental Child Psychology, 2, 219–235
  6. Braukmann, C.J., Fixsen, D.L., Kirigin, K.A., Phillips, E.A., Phillips, E.L., & Wolf, M.M. (1975). "Achievement place: The training and certification of teaching parents". In W.S. Wood (Ed.), Issues in evaluating behavior modification. Champaign, Ill.: Research Press, 131–152
  7. Filcheck, H.A., & McNeil, C.B. (2004). The Use of Token Economies in Preschool Classrooms: Practical and Philosophical Concerns. JEIBI, 1 (1), 95–99 BAO
  8. Ryan, B.P. (2004) Contingency Management and Stuttering in Children, The Behavior Analyst Today, 5 (2), 144–169 BAO
  9. Baer, D.M., & Wolf, M.M. (1970). "The entry into natural communities of reinforcement". In R. Ulrich, T. Stachnik, & J. Mabry (Eds.), Control of human behavior: Volume II. Glenview, Ill.: Scott, Foresman.
  10. Walker, H. (1990). The Acting Out Child. Soporis West.
  11. Higgins, ST, et al., (1991) A behavioral approach to achieving initial cocaine abstinence, Am J of Psychiatry, 148, 1218–1224.
  12. Higgins, ST, et al. (1993). Achieving cocaine abstinence with a behavioral approach. Am J of Psychiatry, 150, 763–769
  13. Lussier, JP, et al. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101, 192–203.
  14. Prendergast ML, Hall EA, Roll J, Warda U. (2007). Use of vouchers to reinforce abstinence and positive behaviors among clients in a drug court treatment program. J. Subst Abuse Treat.
  15. Rohsenow, Damaris J.; Martin, Rosemarie A.; Tidey, Jennifer W.; Colby, Suzanne M.; Monti, Peter M. (January 2017). "Treating smokers in substance treatment with contingent vouchers, nicotine replacement and brief advice adapted for sobriety settings". Journal of Substance Abuse Treatment. 72: 72–79. doi:10.1016/j.jsat.2016.08.012. PMC 5154824. PMID 27658756.
  16. Cancio, E. & Johnson, J.W. (2007). Level Systems Revisited: An Impact Tool For Educating Students with Emotional and Behavioral Disorders. International Journal of Behavioral Consultation and Therapy, 3 (4), 512–527. BAO
  17. Schumacher JE, Milby JB, Wallace D, Meehan DC, Kertesz S, Vuchinich R, Dunning J, Usdan S. (2007). Meta-analysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990–2006). J Consult Clin Psychol., 75 (5): 823–8.
  18. Stitzer ML, Petry N, Peirce J, Kirby K, Killeen T, Roll J, Hamilton J, Stabile PQ, Sterling R, Brown C, Kolodner K, Li R. (2007). Effectiveness of abstinence-based incentives: interaction with intake stimulant test results. J Consult Clin Psychol., 75 (5), 805–11
  19. Petry NM, Alessi SM, Hanson T, Sierra S. (2007). Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients. J Consult Clin Psychol., 75 (6), 983–991
  20. Drebing CE, Van Ormer EA, Mueller L, Hebert M, Penk WE, Petry NM, Rosenheck R, Rounsaville B. (2007). Adding contingency management intervention to vocational rehabilitation: Outcomes for dually diagnosed veterans. J Rehabil Res Dev., 44 (6): 851–66
  21. Ghitza UE, Epstein DH, Preston KL. (Nov. 17 2007) Contingency management reduces injection-related HIV risk behaviors in heroin and cocaine using outpatients. Addict Behav.
  22. Lester KM, Milby JB, Schumacher JE, Vuchinich R, Person S, Clay OJ. (2007). Impact of behavioral contingency management intervention on coping behaviors and PTSD symptom reduction in cocaine-addicted homeless. J Trauma Stress., 20 (4): 565–75.
  23. Olmstead TA, Sindelar JL, Petry NM. (2007). Clinic variation in the cost-effectiveness of contingency management. Am J Addict., 16 (6), 457–60
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