Contingency management

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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).

Contents

Incentive-based contingency management is well-established when used as a clinical behavior analysis (CBA) treatment for substance use disorders, 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 produce 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 are 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 is 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

Related Research Articles

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.

In internal medicine, relapse or recidivism is a recurrence of a past condition. For example, multiple sclerosis and malaria often exhibit peaks of activity and sometimes very long periods of dormancy, followed by relapse or recrudescence.

Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on behaviorism's theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems.

A methadone clinic is a medical facility where medications for opioid use disorder (MOUD) are dispensed-—historically and most commonly methadone, although buprenorphine is also increasingly prescribed. Medically assisted drug therapy treatment is indicated in patients who are opioid-dependent or have a history of opioid dependence. Methadone is a schedule II (USA) opioid analgesic, that is also prescribed for pain management. It is a long-acting opioid that can delay the opioid withdrawal symptoms that patients experience from taking short-acting opioids, like heroin, and allow time for withdrawal management. In the United States, by law, patients must receive methadone under the supervision of a physician, and dispensed through an Opioid Treatment Program (OTP) certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Administration.

Behavioral engineering, also called applied behavior analysis, is intended to identify issues associated with the interface of technology and the human operators in a system and to generate recommended design practices that consider the strengths and limitations of the human operators.

"The behavior of the individual has been shaped according to revelations of 'good conduct' never as the result of experimental study."

A token economy is a system of contingency management based on the systematic reinforcement of target behavior. The reinforcers are symbols or tokens that can be exchanged for other reinforcers. A token economy is based on the principles of operant conditioning and behavioral economics and can be situated within applied behavior analysis. In applied settings token economies are used with children and adults; however, they have been successfully modeled with pigeons in lab settings.

Motivational therapy is a combination of humanistic treatment and enhanced cognitive-behavioral strategies, designed to treat substance use disorders. It is similar to motivational interviewing and motivational enhancement therapy.

An addictive behavior is a behavior, or a stimulus related to a behavior, that is both rewarding and reinforcing, and is associated with the development of an addiction. There are two main forms of addiction: substance use disorders and behavioral addiction. The parallels and distinctions between behavioral addictions and other compulsive behavior disorders like bulimia nervosa and obsessive-compulsive disorder (OCD) are still being researched by behavioral scientists.

Drug addiction recovery groups are voluntary associations of people who share a common desire to overcome their drug addiction. Different groups use different methods, ranging from completely secular to explicitly spiritual. Some programs may advocate a reduction in the use of drugs rather than outright abstention. One survey of members found active involvement in any addiction recovery group correlates with higher chances of maintaining sobriety. Although there is not a difference in whether group or individual therapy is better for the patient, studies show that any therapy increases positive outcomes for patients with substance use disorder. The survey found group participation increased when the individual members' beliefs matched those of their primary support group. Analysis of the survey results found a significant positive correlation between the religiosity of members and their participation in twelve-step programs and to a lesser level in non-religious SMART Recovery groups, the correlation factor being three times smaller for SMART Recovery than for twelve-step addiction recovery groups. Religiosity was inversely related to participation in Secular Organizations for Sobriety.

Cocaine dependence is a neurological disorder that is characterized by withdrawal symptoms upon cessation from cocaine use. It also often coincides with cocaine addiction which is a biopsychosocial disorder characterized by persistent use of cocaine and/or crack despite substantial harm and adverse consequences. The Diagnostic and Statistical Manual of Mental Disorders, classifies problematic cocaine use as a "Stimulant use disorder". The International Classification of Diseases, includes "Cocaine dependence" as a classification (diagnosis) under "Disorders due to use of cocaine".

Neonatal withdrawal or neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) is a withdrawal syndrome of infants after birth caused by in utero exposure to drugs of dependence, most commonly opioids. Common signs and symptoms include tremors, irritability, vomiting, diarrhea, and fever. NAS is primarily diagnosed with a detailed medication history and scoring systems. First-line treatment should begin with non-medication interventions to support neonate growth, though medication interventions may be used in certain situations.

<span class="mw-page-title-main">Addiction</span> Disorder resulting in compulsive behaviours

Addiction is a neuropsychological disorder characterized by a persistent and intense urge to use a drug or engage in a behaviour that produces natural reward, despite substantial harm and other negative consequences. Repetitive drug use often alters brain function in ways that perpetuate craving, and weakens self-control. This phenomenon – drugs reshaping brain function – has led to an understanding of addiction as a brain disorder with a complex variety of psychosocial as well as neurobiological factors that are implicated in addiction's development. Classic signs of addiction include compulsive engagement in rewarding stimuli, preoccupation with substances or behavior, and continued use despite negative consequences. Habits and patterns associated with addiction are typically characterized by immediate gratification, coupled with delayed deleterious effects.

The adolescent community reinforcement approach (A-CRA) is a behavioral treatment for alcohol and other substance use disorders that helps youth, young adults, and families improve access to interpersonal and environmental reinforcers to reduce or stop substance use.

About 1 in 7 Americans suffer from active addiction to a particular substance. Addiction can cause physical, psychological, and emotional harm to those who are affected by it. The American Society of Addiction Medicine defines addiction as "a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences." In the world of psychology and medicine, there are two models that are commonly used in understanding the psychology behind addiction itself. One model is referred to as the disease model of addiction. The disease model suggests that addiction is a diagnosable disease similar to cancer or diabetes. This model attributes addiction to a chemical imbalance in an individual's brain that could be caused by genetics or environmental factors. The second model is the choice model of addiction, which holds that addiction is a result of voluntary actions rather than some dysfunction of the brain. Through this model, addiction is viewed as a choice and is studied through components of the brain such as reward, stress, and memory. Substance addictions relate to drugs, alcohol, and smoking. Process addictions relate to non-substance-related behaviors such as gambling, spending money, sexual activity, gaming, spending time on the internet, and eating.

Nathan H. Azrin was a behavioral modification researcher, psychologist, and university professor. He taught at Southern Illinois University and was the research director of Anna State Hospital between 1958 and 1980. In 1980 he became a professor at Nova Southeastern University, and entered emeritus status at the university in 2010. Azrin was the founder of several research methodologies, including Token Economics, the Community Reinforcement Approach (CRA) on which the CRAFT model was based, Family Behavior Therapy, and habit reversal training. According to fellow psychologist Brian Iwata “Few people have made research contributions equaling Nate’s in either basic or applied behaviour analysis, and none have matched his contributions to both endeavors.”

Community reinforcement approach and family training (CRAFT) is a behavior therapy approach in psychotherapy for treating addiction developed by Robert J. Meyers in the late 1970s. Meyers worked with Nathan Azrin in the early 1970s whilst he was developing his own community reinforcement approach (CRA) which uses operant conditioning techniques to help people learn to reduce the power of their addictions and enjoy healthy living. Meyers adapted CRA to create CRAFT, which he described as CRA that "works through family members." CRAFT combines CRA with family training to equip concerned significant others (CSOs) of addicts with supportive techniques to encourage their loved ones to begin and continue treatment and provides them with defences against addiction's damaging effects on themselves.

Nancy M. Petry was a psychologist known for her research on behavioral treatments for addictive disorders, behavioral pharmacology, impulsivity and compulsive gambling. She was Professor of Medicine at the University of Connecticut Health Center. Petry served as a member of the American Psychiatric Association Workgroup on Substance Use Disorders for the DSM-5 and chaired the Subcommittee on Non-Substance Behavioral Addictions. The latter category includes Internet addiction disorder and problem gambling. She also served as a member of the Board of Advisors of Children and Screens: Institute of Digital Media and Child Development.

Hendrée E. Jones is a researcher on women's substance abuse disorders and its impact on children. She is a professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine, and adjunct professor in the University of North Carolina College of Arts & Sciences Department of Psychology and Neuroscience. Jones is the executive director of the UNC Horizons Program, which is a comprehensive drug treatment program for mothers and their drug-exposed children. She is a consultant for the Substance Abuse and Mental Health Services Administration, the United Nations, and the World Health Organization.

References

  1. ↑ Forness, Steven R.; Kavale, Kenneth A.; Blum, Ilaina M.; Lloyd, John W. (1997). "Mega-Analysis of Meta-Analyses". TEACHING Exceptional Children. 29 (6): 4–9. doi:10.1177/004005999702900601. ISSN   0040-0599. S2CID   148914363.
  2. ↑ Zlomke, L. (2003). Token Economies. The Behavior Analyst Today, 4 (2), 177–184 BAO
  3. ↑ Axelrod, Saul (1973). "Comparison of individual and group contingencies in two special classes". Behavior Therapy. 4 (1): 83–90. doi:10.1016/s0005-7894(73)80076-0. ISSN   0005-7894.
  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, Cecilia E (1965). "Classroom behavior of retarded pupils with token reinforcement". Journal of Experimental Child Psychology. 2 (2): 219–235. doi:10.1016/0022-0965(65)90045-7. ISSN   0022-0965.
  6. ↑ Wolf, Montrose M.; Phillips, Elery L.; Fixsen, Dean L.; Braukmann, Curtis J.; Kirigin, Kathryn A.; Willner, Alan G.; Schumaker, Jean (1976). "Achievement place: The teaching-family model". Child Care Quarterly. 5 (2): 92–103. doi:10.1007/bf01555232. ISSN   0045-6632. S2CID   143728487.
  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. 1 2 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, Joseph E.; Milby, Jesse B.; Wallace, Dennis; Meehan, Dawna-Cricket; Kertesz, Stefan; Vuchinich, Rudy; Dunning, Jonathan; Usdan, Stuart (2007). "Meta-analysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990-2006)". Journal of Consulting and Clinical Psychology. 75 (5): 823–828. doi:10.1037/0022-006X.75.5.823. ISSN   1939-2117. PMID   17907865.
  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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