Contingency Management is the most effective psychological treatment for substance use. 

⏰ Time to read: 10 mins

Contingency Management is an evidence-based approach to drug testing that utilizes a gamified system of rewards and consequences to encourage positive behaviors such as attending sessions and completing drug tests. Studies show that it is the most effective psychological approach for reducing substance use and facilitating recovery despite being underused. By using these frameworks, we believe that we can support the parent-teen relationship by reducing the conflict associated with drug testing and showing up to treatment, creating more trust within the family.

How does Contingency Management work?

For some good bedtime reading 🥱, here is the original handbook from Yale on how and why Contingency Management works. Here is the cheat sheet:  Basically, CM is a program that encourages attendance and engagement through rewards. Eventually, we transition the teen from extrinsic rewards to intrinsic reward systems.

For the nerds: Operant Conditioning & Progressive Reinforcement 

Contingency Management is based on operant conditioning principles. Operant conditioning is a type of learning that happens when rewards and punishments are paired with specific behaviors. Behaviors are reinforced or rewarded so that they are more likely to occur over time, while behaviors that are not desired are punished or ignored and then become less likely to happen.

Conditioning is not a new idea – you have likely heard of “Pavlov’s dog.” Ivan Pavlov, a Russian physiologist, was a pioneer in the study of classical and operant conditioning. In his experiments, he routinely placed meat in a dog’s mouth, which caused the dog to salivate. By accident, Pavlov noticed that the meat was not the only stimulus that caused the dog to salivate. The dog salivated in response to a number of other stimuli associated with the food, such as the sight of the food dish, the sight of the person who brought the food into the room, and the sound of the door closing when the food arrived. Pavlov recognized that the dog’s association of these previously neutral sights and sounds with the food was an important type of learning. This type of learning came to be called classical conditioning.

As it relates to mental health and addiction, classical conditioning could look like feelings of anxiety triggered by the sound of a garage door opening because the noise reminds them of a father who would abuse them upon returning home from work or an individual who experiences cravings for heroin every time they see a spoon, after having used a spoon as a part of their use for so long. We sometimes refer to this phenomenon as a condition cue craving.

Unlike classical conditioning, operant conditioning is the process of modifying behavior by intentionally creating associations between behaviors and consequences. In the case of Contingency Management, positive reinforcement is used to incentivize a specific target behavior. That looks like administering a reward after a target behavior is performed, e.g., a $5 reward for a negative drug test. The goal of reinforcement is always to increase the frequency of a desired behavior. 

Contingency Management also uses progressive reinforcement by increasing the value of rewards with each consecutive, successful behavioral response. For example, a patient could receive a $3 reward for every negative urine screen for the first month. Then, in month two, every other week. The amount of rewards can increase along with the frequency of the behavioral tests decreasing. So instead of $3, it’s $5, then $10. Through modifying and lessening the tests and extrinsic rewards, Contingency Management facilitates a shift from extrinsic to intrinsic motivation and a more internal locus of control. The increasingly longer lengths of time between rewards encourage the development of delaying gratification and acting through a more long-term lens.

Why Contingency Management works so well for teens

Virtual Contingency Management programs are effective for teens with substance use issues for three reasons:

1. Feedback is immediate.

2. Sobriety is framed as an achievable goal rather than a demand.

3. It’s engaging and keeps them in the program. 

Immediate Feedback

Often, in treatment programs, you don’t get the satisfaction of getting “better” or feeling “better” right away. Recovery can be a long and painful journey and feel like “forever” – especially if you’re a teenager. Contingency management gives immediate feedback and celebrates small wins. This immediate feedback system provides ongoing motivation for even the darkest days. 

Engagement

Contingency Management is especially promising in adolescent recovery because it significantly boosts engagement. Engagement is a constant struggle between teenagers and… well, everyone. Teens are notorious for being ‘too cool,’ resorting to eye-rolling or even tantrums when faced with tasks they’re uninterested in. Schools, parents, and treatment programs invest considerable effort in boosting teen engagement, a crucial factor for successful treatment outcomes. Rewards-based systems can effectively tackle engagement issues and motivate resistant teens. Approaching recovery with a more enjoyable, gamified strategy proves to be a potent tool in engaging uninterested and resistant adolescent minds.

For rewards in Contingency Management to be effective, they must surpass the allure of substance use. They should be:

  • Tangible: Rewards should be physical, something the teens can hold or experience directly. 
  • Desirable: Rewards must appeal to teenagers and align with their interests or preferences.
  • Escalating: Gradually increasing the value or appeal of rewards maintains motivation over time.
  • Objective: The criteria for earning rewards should be clear, measurable, and consistent. Objectivity ensures fairness and transparency, reducing confusion and fostering a sense of achievement.

Sobriety as a goal, not a demand

Instead of expecting sobriety, which for most teens is unrealistic and a great way to set them up to fail, Contingency Management focuses on honesty and incremental goal setting. Rather than focusing on permanent or long-term abstinence as the immediate goal, we use Contingency Management to celebrate small wins and, over time, build up to bigger wins. Just like when trying to lose weight, we can’t decide just to drop 50 pounds – losing 2 or 3 pounds a week is a more manageable and achievable goal. Results take time.

Drug testing often strains the parent + teen relationship 

Drug testing often becomes a point of tension between parents and their teenagers. It can create a challenging scenario where parents, striving to help their teens, confront resistance from their children, who are eager for privacy and independence. This clash often leads to strained relationships, the harboring of secrets, and a sense of resentment.

In such circumstances, parents can swing between expressing anger, feeling betrayed, and inadvertently punishing their teen’s honesty to adopting a peacekeeping approach that enables, denies, or feigns ignorance of the drug use. These shifts, while understandable, usually create distress and confusion for teenagers.

Despite these issues, transparency is paramount in substance use treatment. Accurate information is vital for the treatment team to make meaningful progress. This requires understanding the details of substance use, which involves drug testing. 

Contingency management offers a solution to defuse this dynamic. By placing the accountability for drug testing on the treatment team and teenager, rather than solely on parents, it eases the burden on families and fosters a more supportive environment for treatment.

If it works so well, why is no one using it? 

The primary barrier lies in the absence of insurance coverage. Insurance companies refuse to cover this treatment, rendering it financially inaccessible for most families. Although attempts have been made to secure grant funding for these programs, only privately funded programs or those backed by major funders can typically afford to implement them. Furthermore, the logistical complexity of this kind of program poses a challenge, especially for an already overworked healthcare workforce. We also theorize that the implementation gap plays a role here as well – it often takes roughly 20 years for new research findings to be fully integrated into practical use.

We hope this changes! There has been a recent rise in stimulant use over the last year. Contingency Management is a hopeful approach for treating stimulant use disorders. Since there aren’t approved medications for these disorders, unlike opioid use, it becomes an appealing method to address problems related to meth, cocaine, and other substances that have surged over the last year.

We now offer Contingency Management at Antelope for teens struggling with substance use 🎉

We are excited to now be offering contingency management for teens virtually at Antelope. As more measurement-based care opportunities emerge, we hope to see additional programs leaning into these types of effective and evidence-based interventions. We are optimistic about contingency management gaining more traction.

*Graphs are from Dynamicare’s Contingency Management Studies!

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