Contingency management (CM) is an approach and acknowledged as a type of behavioural therapy which is commonly based on the operant conditioning. The principle behind the operant conditioning is to help individuals to learn a new behaviour or adjust their behaviour by its consequences. The majority of the substance users may decide to obtain contingency management treatment due to the negative consequences of drug use, external negative consequences or personal negative consequences. Therefore, the aim of contingency management treatment is to modify the behaviour of substance users by rewarding their positive behaviour to increase the occurrence of the desired behaviour to happen in the future. Contingency management treatment can be provided to an individual as independently depending on their needs, or it can be provided in combination with other treatment methods including; cognitive-behavioural therapy, medication management, and motivational interviewing (Patterson, 2017).
Contingency management is identified to be an effective treatment for the substance use disorders; however, there are still criticisms on the effectiveness of the treatment of contingency management for the treatment of addiction and dependence (Patterson, 2017). The benefit of the contingency management is using punishment method sparingly as the main belief behind the CM treatment is to increase the positive behaviour with reinforcements rather than decreasing the negative behaviour by heavily using punishment idea. Patterson stated that using punishment likely to have a negative impact on the relationship between the person giving the consequence and receiving it and individuals may not show engagement in the treatment, which may affect the recovery (Patterson, 2017). Petry and Stitzer shared a similar view as they supported that punishment is less likely to teach new behaviour to the individuals as there is a high potential for them to continue performing the same behaviour when the punishment stopped. Also, stated that punishment can imply a failure to the addictive individuals and may promote poor self-esteem (Petry and Stitzer, 2002).
Prize-based incentives are one of the methods of contingency management. With this method, when the clients have shown a positive behaviour (e.g. drug-free urine sample) to the practitioners, they gain a chance to earn draws from a bowl for a cash prize. The bowl contains slips of paper writing the value of the prize alternating from a dollar to a hundred dollar. There are some criticisms made on prize incentives contingency management as some arguments were made on prize bowl due to being similar to gambling (Petry and Stitzer, 2002). In community treatment centres, the practitioners were concerned that this type of approach encourages gambling due to the involvement of the chance element. They were also worried that this intervention procedure might increase the client’s gambling behaviour (NIDA,2012). This criticism further supported by Shaffer et al. as the data suggested individuals with gambling problems are more prevalent in substance users (Shaffer et al., 1999). However, while this was acceptable, several studies were contrasting with this viewpoint as they found no relationship between gambling addiction and prize incentives in substance abusers. (Petry and Martin, 2002). The clinical trials show that prize incentives CM is sufficient for the treatment of the substance abusers. A study showed that gambling problems don’t influence the efficacy of the prize incentives CM procedure (Petry and Alessi, 2010). Further to this, the findings from the meta-analysis study demonstrated that the effect size of prize incentives CM for short term is 0.46 which is moderate. This was concluded having a meaningful effect in the treatment of substance use as the clients’ increased their abstinence at the time of the intervention was implemented (Benishek et al., 2014). However, it’s worth mentioning that, the finding of this meta-analysis in prize incentives CM method for substance use disorder doesn’t seem increase nor persist long-term (6 months) abstinence (Benishek et al., 2014). Therefore, due to this, this reinforcement procedure may not be used regularly in the treatment of substance abuser in comparison to voucher-based incentives CM.
Voucher as a reinforcer is also used in the contingency management to encourage clients who have drug addictive behaviour to change that to positive behaviour. The clients receive vouchers for providing a drug-free urine sample, and with the increase of continual supply of negative urine sample, the value of the vouchers increases. Many studies identified the voucher-based procedure has been effective in supporting drug abstinence in particular cocaine and opioids (reference). Another study also concluded the effectiveness of this procedure as the meta-analysis of voucher-based showed significant treatment outcomes in patients with substance abuse (Lussier et al., 2006). However, there are some literatures demonstrating conflicting results on whether voucher-based reinforcement provides long-term abstinence or not. The majority of them indicated that voucher-based method has better abstinence (Higgins et al. 2000; Lussier et al., 2006); whereas others reported observing relapse in long-term once the reinforcement discontinued (Silverman et al. 1996a).
The above statements supported the effectiveness of the contingency management for both of the prize and voucher-based incentives procedures. But, a concern was raised for contingency management methods. Rawson et al. mentioned that some of the laboratory-based CM clinical trials determined that drug users revert back to behaviour in a pre-intervention period when reinforcers not given. Similar concerns from other studies about the long-term abstinence can also be noted at above. But, at above, supporting studies for the long-term effect of contingency management can be seen as well.
Therefore, it is clearly noticed that long-term abstinence effect of the contingency management is not concluded for sure. As other studies support the sense that the behaviour would likely relapse back to its original unwanted behaviour once the rewards no longer offered to the clients. So, further studies should be undertaken to examine the long-term effect of CM rather than short-term to identify if relapse occurs in the absences of the rewards. However, even though there are conflicting results, overall, the benefits of the contingency management clearly determined in the existing literature in the treatment of drug addictive behaviours (Petry et al., 2002; Higgins et al.,2000; and Petry et al., 2005).
The cost of contingency management is another criticism, and many of the studies consider this concern in their research and share the same view. The criticism is the approach being too expensive, in particular, voucher. In order to help and encourage the clients to build a strong relationship between behaviour and consequences, the magnitude of the incentive or the choice of reinforcer is essential. If the client showed no interest in the particular reward after the desired behaviour is exhibited, that might increase the possibility of having cravings and failure. Therefore, may be, spending for the reinforcers may need to be higher at the beginning to help clients to achieve their goals. It is known from the kinds of literature that contingency management is an effective procedure in treating drug dependence. However, the voucher program already costs more without the inclusion of transportation cost of the staff to purchase the items. The voucher studies have shown a patient can earn a voucher that worth about $1000 and average earnings were about $450-600 (Higgins and colleagues, 1993, 1994, 2000a). Some researches support that higher average cost of the voucher is needed to gain improved outcome at the end of the treatment. In addition to this, similar views also obtained from other studies, stating that there is a strong correlation between the magnitude of vouchers and the efficacy of the procedure (Petry,2000).
Other studies also identified that the effectiveness of CM procedure drops when the magnitude of the voucher gets lower and shows fewer progressive effects (Dallery et al., 2001; Jones et al., 2000; Stitzer & Bigelow, 1984; Petry,2000). However, in contrast to this, a finding from Carroll et al. (2002) showed that higher magnitude voucher ($1152) did not increase abstinence nor improved the outcome when compared to lower magnitude voucher ($562). Even though there are some studies supports that magnitude doesn’t influence the effectiveness of the CM procedure, my personal view is that it would be difficult for the individual with drug use behaviour to maintain the desired behaviour with a lower magnitude of vouchers. As it is necessary to consider that drugs are strong reinforcers too, so abstinence may not take longer.
Prize-based CM was created as an alternative method to the voucher-based CM to reduce the cost of the treatment program and to increase the possibility of using the CM procedure in a different practice setting (Petry and Stitzer, 2002; Petry, 2000). Some studies were undertaken to assess the cost-effectiveness of CM procedures while maintaining the efficacy of the procedure. The studies found that prize-based CM is more cost-effective than voucher-based CM procedure when the cash prize is greater than $166 in a community treatment centres for the longest length of confirmed abstinence (Olmstead and Petry, 2009).
Some studies also examined the effectiveness of cash rather than a voucher in supporting drug abstinence and also to identify a way to make CM program more cost-effective (Petry and Stitzer, 2002). For example, a study from Shaner et al. found that giving $25 cash to two cocaine-abusing schizophrenic clients reduced their use of cocaine (Shaner et al., 1997). So, offering cash could be less expensive than a voucher for the clients having addictive drug behaviour (Petry, 2000). As it could be easier to manage than voucher program, but it needs to be considered that cash may motivate a client to buy a drug instead of encouraging them to change their targeted behaviour by cash.
Furthermore, a study that was assessing the effectiveness of a low-cost CM procedure in reducing concomitant use of cocaine and opioid in methadone patients (Petry and Martin, 2002). A finding from this study proposed that a prize-based program could be suitable to use in the community-based setting (Petry and Martin, 2002). As the patients in the CM condition earned $137 of prizes and the effect of the abstinence remained effective during a 6 months follow-up (Petry and Martin, 2002).
However, a different study showed that cost-effectiveness of the CM program varied through the eight clinics in the National Institute on Drug Abuse Clinical Trials Network MIEDAR trial (Olmstead et al., 2007). As the incremental cost of using CM was ranging from $306 to $582 for each patient throughout the clinics, and incremental cost-effectiveness ratios (ICERs) for the longest duration of continuous stimulant abstinence (LDA) were ranging from $145 to $666 (Olmstead et al., 2007). Therefore, from these results and other findings stated above, it can be concluded that it is challenging to apply CM program to a different setting as the cost-effectiveness differs among different settings.
However, the results from MIEDAR trial study also show a possibility for improvement of CM procedure for the clinics that are identified having less cost-effective CM procedure (Olmstead et al., 2007). The reason behind the variations can be studied by comparing each of the clinics together to understand how they differ, and from that, the clinics that are less cost-effective can be made more cost-effective for this CM intervention. So, this study indicates that overall cost-effectiveness of CM can be improved.
Another criticism made for CM program is that clients were motivated by external reinforcers rather than internal motivation to change their behaviour, and also others indicate that internal motivation may be decreased when the CM program is completed with benefits and external reinforcers are stopped, which may result in undesired behaviour (Petry, 2010). However, even though this criticism is made, to my knowledge, there is not a study supporting this criticism. There are few studies considered the motivation aspect of the CM program and the external rewards that are provided to the clients, but the findings of some studies indicated that CM program neither increases or decreases the motivation of the client having drug additive behaviour (Ledgerwood and Petry, 2005).
But in contrast to that, in Silverman’s study, methadone patients who were receiving treatment for cocaine, they state that this incentive program assisted them to boost their motivation to persist their abstinence (Petry and Stitzer, 2002). So, from this statement, two things could be assumed. First of all, these patients may truly recognise that their achievement of wanted behaviour through their own motivation rather than external rewards as they may already have the motivation in them at the beginning of the intervention to change the unwanted behaviour but needed some push. The second assumption could be that some others may have achieved the wanted behaviour with the help of external rewards as they might not have the internal motivation at the pre-intervention stage, and the sense of motivation may be developed for these patients through the external reinforcers and contingent rewards, and their motivation may be influenced by this CM program. While it is debatable that where is the motivation comes from, particularly internal motivation. Even if the external rewards influenced the patient’s motivation, it helped them to control and maintain their abstinence, and decreased the possibility of using drugs; and this should be the focused purpose.
Only the studies of Petry mentioned some ethical concerns of contingency management, which was generally the main criticism about this intervention program. Some of the ethical concerns such as exchanging prizes or vouchers for the drugs and encouragement for gambling through prized-based CM program was previously mentioned. The idea that is not mentioned earlier about ethical issues is that certain population was founding unethical to pay what the drug abusers should be responsible doing anyway (Petry, 2006). However, personally, I do not share the same views as I believe that these individuals should be regained back to the society rather than showing discouragement. This is because, with this statement – ‘unethical to pay what the drug abusers should be responsible doing anyway’ (Petry, 2006), I felt that there is an attempt to isolate drug abusers from the society and there is a sort of underlying indication that it is not good action to make payment to those clients. But I believe that they should be felt valued and the actions that are best for them needs to be taken to recur their wanted behaviour again as previously so that they can think and realise how important they are for this society. I assume that they were exhibiting the wanted behaviour before they become substance abusers and they may be beneficial individuals to the society, so now, because they have taken a step that leads to a negative consequence. Hence, I am against with this sort of emotionally-based criticism by stating it is unethical to pay drug abusers to do what they should do.
Among the supportive and unsupportive criticisms of studies about contingency management mentioned above, generally, I believe the contingency management is an effective approach even though it comprises some concerns, which can be improved. In particular, I think voucher-based CM is more beneficial than the prize-based CM intervention program. This is because even if vouchers as a reward is more expensive, I feel that it would be more appealing to the clients as a voucher is exchangeable for entertainments, food products, beauty, and services. So, they have a choice to obtain their preferred items, which may help them to remain abstinent, but I believe this is also about dedication and how they keen to achieve their goal, which is the wanted the targeted behaviour.
Although prize-based CM is less expensive in comparison to voucher-based, I am still concerned about gambling. This is because when I read this method of CM program, it remained me about the lottery and similar chance games while the studies concluding that CM does not contribute to gambling, no correlation and some stated that the similarities of CM program to gambling are only superficial (Petry,2006). So, though there is some evidence, I still believe further investigation may be needed as this method help me to think about lottery even though I never played that kind of games (i.e. lottery, chance games and gambling games) and I am not a drug abuser.
Hence, in short, if this method triggered lottery and chance games to me, it may do the same for clients who are in the intervention treatment for addictive drug behaviour who also has issues with gambling. However, it may be essential to consider what root cause did make me think about lottery, so similar response might not be gained from those clients and as contingency management based on the operant conditioning which is behavioural therapy, it does not identify the root cause. But I do agree with the studies that mentioning the avoidance of prize-based method in clients who previously had a problem with gambling (Petry and Stitzer, 2002).
From the evidence of the studies, I acknowledged that implementation of this approach to a setting is very challenging due to the several concerns including ethical issues as well. This is because each practice setting needs to consider specific duration period for this intervention program depending on their patient characteristics as I feel the length of the intervention procedure likely to differ for the different patient group. In most of the studies that are conducted in the USA, the longest duration time for the CM program lasted for 6 months, and some of them were 3 months for each patient. I think the optimum length of the CM intervention program needs to be 10 months because, from the studies, it is seen that patients started showing positive behaviour and beginning to remain abstinent for longer within 3 months.
However, when the patient’s targeted behaviour is monitored after 3 months, they did not show a significant difference in maintaining their abstinence for a lengthier time, i.e. 6 months as I would be expecting a huge difference between 3 months and 6 months intervention program. This could be because the reinforcers may motivate the patients at the beginning and as the intervention program progressed their motivation could be slightly decreased or remained stable due to getting used to the procedure. Or, as the patients know how long the CM intervention program would last for, their motivation to achieve their goal could be influenced by the duration time. Because the patients might feel they might not be successful in that period so that they might find the length of the program shorter. Thus, I believe that duration could impact the patient’s motivation so optimum length such as 10 months could be ideal to help patients to control their abstinence for longer including the absence of the rewards. Whereas 3 or 6 months could be shorter for a patient that are substance abusers as I believe a relapse may occur suddenly even though the studies indicate the opposite of this.
The selection of rewards is also vital as they need to be interesting and needs be an item that patients expected to fancy. Therefore, as already mentioned that choice is given to a patient to choose from voucher-based CM, I believe that it is also important to gather information about a sort of incentive they would having as with this way, they would feel valued and cared for. If the items they would like to have is too expensive, then staff can consider purchasing similar incentives for achieving positive behaviour. Therefore, if the patient’s preference were ignored, then the CM intervention program may likely to waste wealth as it already costs too much.
To conclude, this essay showed with the evidence from the studies that CM program is useful in the treatment of drug abusers along with ethical concerns that seen as a barrier for the implementation to the practice settings. There are only a small number of studies mentioned about the application of this intervention to the practice, so this could mean just a few intervention providers considered this treatment program. Other providers were likely to be concerned about its implementation due to finance, management and current culture of the countries in serving drug therapy.
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