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-behavioral therapy (CBT) framework as well.

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]

Effectiveness in addiction programs

A meta-analysis of contingency management in drug programs showed that it has a large effect. [16] These contingencies are delivered based on abstinence and attendance goals [17] [18] 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 [19] [20] and homelessness. [21] Overall contingency management is an effective and cost-efficient addition to drug treatment. [22]

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]

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. [23]

Organizations

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

See also

Related Research Articles

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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, and 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 medical consequences that can be caused.

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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.

Cue reactivity is a type of learned response which is observed in individuals with an addiction and involves significant physiological and psychological reactions to presentations of drug-related stimuli. The central tenet of cue reactivity is that cues previously predicting receipt of drug reward under certain conditions can evoke stimulus associated responses such as urges to use drugs. In other words, learned cues can signal drug reward, in that cues previously associated with drug use can elicit cue-reactivity such as arousal, anticipation, and changes in behavioral motivation. Responses to a drug cue can be physiological, behavioral, or symbolic expressive. The clinical utility of cue reactivity is based on the conceptualization that drug cues elicit craving which is a critical factor in the maintenance and relapse to drug use. Additionally, cue reactivity allows for the development of testable hypotheses grounded in established theories of human behavior. Therefore, researchers have leveraged the cue reactivity paradigm to study addiction, antecedents of relapse, and craving, translate pre-clinical findings to clinical samples, and contribute to the development of new treatment methods. Testing cue reactivity in human samples involves exposing individuals with a substance use disorder to drug-related cues and drug neutral cues, and then measuring their reactions by assessing changes in self-reported drug craving and physiological responses.

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<span class="mw-page-title-main">Polysubstance dependence</span> A type of substance use disorder

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

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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 is a behavior therapy approach in psychotherapy for treating addiction developed by Robert J. Myers 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 assist those with addictions live healthily. 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 commence 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

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  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.
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  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. ↑ 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.
  17. ↑ 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
  18. ↑ 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
  19. ↑ 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
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ Olmstead TA, Sindelar JL, Petry NM. (2007). Clinic variation in the cost-effectiveness of contingency management. Am J Addict., 16 (6), 457–60
  23. ↑ 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
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