Contingency management

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Contingency management and self-transcendence

Contingency management (CM) is a set of techniques that focus on changing specified behaviours by using incentives or consequences. CM has been widely used in the treatment of drug misuse, especially for opioids, stimulants and cannabis. In this article, we will explore how CM can also enhance self-transcendence, which is the ability to go beyond one’s personal boundaries and connect with a larger reality. self-transcendence has been linked to positive outcomes such as wellbeing, meaning in life, and recovery from addiction. We will review the evidence for CM and self-transcendence, discuss the possible mechanisms of action, and suggest some implications for practice and research.

Contingency management techniques

Contingency management is a type of behavioural therapy that uses rewards and consequences to change undesirable behaviours. It is based on the principle of operant conditioning, which states that behaviours are influenced by their outcomes. Contingency management can be used to treat various problems, such as substance use disorders, gambling addiction, obesity, and smoking cessation.

Some of the techniques of contingency management are:

• Voucher-based reinforcement: This technique involves giving vouchers or coupons that can be exchanged for goods or services to clients who achieve certain goals, such as abstaining from drug use or attending therapy sessions. The vouchers increase in value as the clients maintain their progress. This technique has been shown to be effective for treating cocaine and opioid dependence.
• Prize incentives: This technique involves giving clients the opportunity to win prizes, such as cash or gift cards, for meeting their behavioural goals. The prizes are usually drawn from a bowl or a computer program, and the chances of winning depend on the number of positive behaviours the clients have performed. This technique has been shown to be effective for treating alcohol, cocaine, marijuana, and methamphetamine dependence.
• Token economy: This technique involves giving tokens or points to the clients for engaging in desirable behaviours, such as completing homework assignments or following rules. The tokens can be exchanged for privileges or rewards, such as extra leisure time or access to recreational activities. This technique has been shown to be effective for treating children and adolescents with conduct problems, attention-deficit/hyperactivity disorder, and autism spectrum disorder.
• Medication take-home privileges: This technique involves allowing clients who are on medication-assisted treatment for opioid dependence to take home their medication doses instead of having to visit a clinic every day. The take-home privileges are contingent on the clients’ compliance with treatment requirements, such as submitting negative drug tests or attending counselling sessions. This technique has been shown to improve retention and adherence to treatment.
• Self-reinforcement: This involves rewarding oneself for achieving a target behaviour, such as by engaging in a pleasant activity, giving oneself praise, or buying oneself a gift. Self-reinforcement can help to enhance self-esteem and self-efficacy and foster a sense of autonomy and responsibility.
• Community reinforcement approach and family training (CRAFT): This involves training family members or significant others to provide positive reinforcement and support for the person with SUD, and to avoid enabling or punishing behaviours. CRAFT can help to improve the quality of interpersonal relationships and increase the likelihood of engaging in treatment.

Contingency management is a flexible and adaptable approach that can be tailored to the specific needs and preferences of each client. It can also be combined with other forms of therapy, such as cognitive-behavioural therapy or motivational interviewing, to enhance its effectiveness. Contingency management aims to help clients develop self-control and self-efficacy by reinforcing positive behaviours and discouraging negative ones.

Mechanisms of action

The mechanisms of action in CM are based on the principles of operant conditioning and behavioural economics. Operant conditioning states that behaviours are influenced by their consequences, and that positive consequences (rewards) increase the likelihood of repeating a behaviour, while negative consequences (punishments) decrease it.

Behavioural economics states that people make choices based on the costs and benefits of different alternatives, and that these choices are influenced by factors such as availability, immediacy, and magnitude of the outcomes. CM applies these principles by providing tangible rewards (such as vouchers, money, or prizes) for engaging in target behaviours (such as abstaining from substance use, attending treatment sessions, or completing homework assignments), and withholding rewards for failing to do so.

The rewards are contingent on objective evidence of the target behaviour (such as urine tests, attendance records, or homework completion). By doing so, CM increases the value and attractiveness of the target behaviour relative to the alternative behaviour, and thus motivates the individual to change their behaviour to obtain the rewards.

CM and self-transcendence

self-transcendence is a psychological construct that refers to the ability to go beyond one’s self-interest and ego boundaries, and connect with something greater, such as nature, humanity, or spirituality. This can enhance wellbeing, meaning, and purpose in life. self-transcendence can also facilitate recovery from drug misuse by increasing motivation, coping skills, and social support.

CM can relate to self-transcendence in several ways. One possible way is that CM can help people who misuse drugs to achieve short-term goals that are consistent with their long-term values and aspirations, such as improving their health, relationships, or career. By doing so, CM can increase their sense of self-efficacy and self-worth, which can foster self-transcendence.

Another possible way is that CM can encourage people who misuse drugs to engage in activities that promote self-transcendence, such as volunteering, meditation, or art therapy. By doing so, CM can enhance their positive emotions and spiritual experiences, which can also foster self-transcendence.

Evidence of efficacy

CM has been shown to be effective in treating various types of substance use disorders, including opioid, cocaine, methamphetamine, nicotine, and alcohol dependence. The evidence for the efficacy of CM comes from several sources, such as randomized controlled trials, meta-analyses, systematic reviews, and cost-effectiveness studies. Some of the main findings from these sources are:

• CM can significantly increase the rates of abstinence from substance use compared to standard care or other psychosocial interventions, especially when combined with pharmacotherapy or cognitive-behavioural therapy.
• It can improve treatment retention, medication adherence, and other treatment outcomes, such as HIV risk behaviours, psychiatric symptoms, and quality of life.
• CM can be adapted to different settings, populations, and substances of abuse, and can be delivered by various providers, such as counsellors, nurses, or peers.
• Also, CM can be cost-effective and cost-saving in the long term, as it can reduce health care utilization, criminal justice involvement, and social costs associated with substance use disorders.

In conclusion, CM is a well-established and evidence-based intervention that can enhance the treatment of substance use disorders and improve the lives of individuals with these conditions.

Example studies

Some examples of these studies are:

• A meta-analysis of 50 randomized controlled trials found that CM was superior to control conditions in reducing drug use and increasing treatment retention across different substances and settings (Lussier et al., 2006).
• A large-scale multisite trial of CM for cocaine dependence demonstrated that CM significantly increased cocaine abstinence rates and treatment attendance compared to standard care (Higgins et al., 2003).
• A randomized trial of CM for methamphetamine dependence showed that CM enhanced the effects of cognitive-behavioural therapy and increased methamphetamine abstinence and treatment completion rates (Roll et al., 2006).
• A systematic review of 69 studies of CM for smoking cessation concluded that CM was effective in increasing quit rates and reducing relapse rates, especially when combined with pharmacotherapy (Stead et al., 2017).
• A randomized trial of CM for alcohol dependence found that CM improved drinking outcomes and increased adherence to naltrexone medication compared to standard care (Petry et al., 2004).

Further reading

Here are some weblinks for further reading:

Contingency Management: Principles and Practice – A comprehensive guide to the theory and practice of contingency management, written by experts in the field. https://www.amazon.com/Contingency-Management-Principles-Practice/dp/019989815X

Contingency Management for Substance Abuse Treatment: A Guide to Implementing This Evidence-Based Practice – A practical handbook for clinicians who want to use contingency management in their practice, with case examples and tips. https://www.amazon.com/Contingency-Management-Substance-Treatment-Evidence-Based/dp/0415882898

Contingency Management for Addiction Treatment – A website that provides information and resources on contingency management, including a toolkit, videos, and FAQs. https://cm4addictiontreatment.org/

Contingency Management in Addiction Treatment – A podcast episode that features an interview with Dr. Nancy Petry, a leading researcher on contingency management. https://www.podbean.com/media/share/pb-9xq3f-fa0e7c
Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine) – A summary of the evidence and recommendations for contingency management interventions for different substances, from the National Institute on Drug Abuse. https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/contingency-management-interventions-motivational-incentives