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).


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).

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]


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

See also

Related Research Articles

Substance abuse Harmful use of a drug including alcohol

Substance abuse, also known as drug abuse, is use of a drug in amounts or by methods which are harmful to the individual or others. It is a form of substance-related disorder. Differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behaviour occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.

Operant conditioning is a type of associative learning process through which the strength of a behavior is modified by reinforcement or punishment. It is also a procedure that is used to bring about such learning.

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 cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

Opioid use disorder substance abuse disorder that involves the recurring use of opioid drugs despite negative consequences

Opioid use disorder (OUD) is a substance use disorder relating to the use of an opioid. Any such disorder causes significant impairment or distress. Signs of the disorder include a strong desire to use opioids, increased tolerance to opioids, difficulty fulfilling obligations, trouble reducing use, and withdrawal symptoms with discontinuation. Opioid withdrawal symptoms may include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are components of a substance use disorder. Complications may include opioid overdose, suicide, HIV/AIDS, hepatitis C, and problems at school, work, or home.

In 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 an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use. 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.

Behavior therapy or behavioral psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviorism and/or cognitive psychology. It looks at specific, learned behaviors and how the environment, or other people's mental states, influences those behaviors, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behavior analysts or cognitive-behavior therapists. They tend to look for treatment outcomes that are objectively measurable. Behavior 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.

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 abuse. It is similar to motivational interviewing and motivational enhancement therapy.

Neonatal withdrawal Medical condition in newborn babies caused by drugs taken by the mother before birth

Neonatal withdrawal or neonatal abstinence syndrome (NAS) is a withdrawal syndrome of infants after birth caused by in utero exposure to drugs of dependence. There are two types of NAS: prenatal and postnatal. Prenatal NAS is caused by discontinuation of drugs taken by the pregnant mother, while postnatal NAS is caused by discontinuation of drugs directly to the infant.

Addiction Compulsive engagement in rewarding stimuli despite adverse consequences

Addiction is a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences. Despite the involvement of a number of psychosocial factors, a biological process—one that is induced by repeated exposure to an addictive stimulus—is the core pathology that drives the development and maintenance of an addiction, according to the "brain disease model" of addiction. However, many scholars who study addiction argue that the brain disease model is incomplete and misleading.

Behavioral marital therapy, sometimes called behavioral couples therapy, has its origins in behaviorism and is a form of behavior therapy. The theory is rooted in social learning theory and behavior analysis. As a model, it is constantly being revised as new research presents.

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.

Methadone maintenance treatment is the use of methadone, administered over a prolonged period of time, as treatment for someone who is addicted to opioids such as heroin, where detoxification has been unsuccessful and/or admittance to a substance abuse treatment facility requires complete abstinence. "Methadone maintenance makes possible a first step toward social rehabilitation" because it allows addicts to avoid the uncomfortable withdrawal symptoms that result from complete abstinence. Methadone maintenance can also be used for patients who suffer with severe pain problems that are resistant to other drugs.

Addiction psychology mostly comprises the clinical psychology and abnormal psychology disciplines and fosters the application of information obtained from research in an effort to appropriately diagnose, evaluate, treat, and support clients dealing without addiction. Throughout the treatment process addiction psychologists encourage behaviors that build wellness and emotional resilience to their physical, mental and emotional problems.

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.


  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. 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 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