What Is Contingency Management?
Contingency management as an addiction treatment tool is a form of positive reinforcement. Someone participating in such a program may receive vouchers for food, movies or gas when they follow the steps of their plan.
Operant Conditioning: The Basics of Behavioral Change
Operant conditioning and the science behind it date back to the 1930s. Both negative and positive reinforcement concepts have been around longer than that, but the scientific data and related experiments are attributed to B.F. Skinner.
Negative Reinforcements
Functionally, negative reinforcement can be used to train people to choose certain behaviors. This process can be explained simply. If you set an alarm each day, a loud and possibly irritating noise will interrupt your sleep until you do something about it. Act on the alarm clock and the noise goes away. You have removed the negative, or the noise, and gained something that pleases you, which is quiet.
The stronger version of negative reinforcement is punishment. Properly applied, punishment can be an appropriate tool to stop inappropriate behavior. Punishment has been used to correct criminal behavior often associated with drug use. However, the legal system does not always provide an immediate and consistent negative experience to prevent people from continuing their illegal behavior. An addict who steals from another person to come up with cash for drugs may eventually be punished with jail time for theft. However, if they have successfully stolen from others before, light legal punishments may not help change their future intentions to do what they have to do to get drugs.
Positive Reinforcement
Positive reinforcement refers to rewarding a desired behavior with a positive consequence. A child may clean their room as instructed and receive a treat or a toy. If the child then chooses to clean their room on their own the next time, the same positive reinforcement may be needed to make the habit stick. Such treats or toys are known as tangible reinforcements. When the parent stops using them, the good behavior may go away.
Token Reinforcements: More Choices, Longer Benefits
Contingency management in drug rehab is generally related to token reinforcers. A token is something that can be exchanged for something else. For example, someone dealing with opioid addiction may have the option to choose a bus token or gas gift card, which can cover the cost of visiting the testing site.
There is great power in earning a token reinforcement. With a token in your pocket, you can choose to seek help. Tokens offer a chance to rebuild a sense of control over your actions and your life that you may have lost.
The Chemistry of Addiction
One of the greatest challenges of addiction is that, at least in the early stages, addictive substances offer a lot of positive feelings. The first beer after a hard day allows you to feel a certain satisfaction. Eventually, getting to that level of relaxation and pleasure takes more than one beer. Your body, brain, and spirit grow so accustomed to the feelings created by alcohol that you crave or need it.
Many illegal drugs overload the dopamine receptors in the brain to the point that they shut down. In such cases, the only way to feel that similar pleasure is to use more of the drug. For addicts who are actively using, punishment therapies can lead to agonizing withdrawal.
Helping addicts manage detox and go through withdrawal often takes positive reinforcement from many angles. The early stages may simply include hydration and nutritional support to move past the harshest cravings and the physical symptoms that come with physical withdrawal. Once this difficult phase has been overcome, training the brain to stop seeking the pleasure provided by drugs and alcohol will take many types of support. This support can include rewards for positive choices.
Long-Term Benefits of Contingency Management
One of the greatest benefits of contingency management as part of long-term outpatient rehab is that people come back more regularly. For those amid a court-appointed rehab process, the process of learning to live without using may not feel like it provides many benefits. Addicts who have lost connection with friends and family due to drug use may feel a loss of community when working through rehab, leading to isolation and despair. The friends you used drugs with may not have been good for you, but they did prevent you from being alone. Tokens and rewards of contingency management can make the rehab process a more rewarding experience.
There is also great confidence gained in earning something. For people who have lost control of their lives due to alcohol and drug use, the function of a token is tangible. You take the required action and earn the expected reward. The benefit is immediate and is tied to the action that earned it. The token is also portable. If you don’t need to use this movie pass or grocery voucher right away, you can save it for something you deem necessary. It’s a resource that you control. It is also altruistic. Many people in the grip of deep addiction find that the drug is high on the list of what is necessary for survival. Their ability to care for others is limited, even if they realize that they are neglecting their household. To be able to use a token for the benefit of another can create a tremendous physical and emotional benefit. Giving fires up the pleasure centers in the brain.
Those who suffer from underlying medical conditions also gain benefits from contingency management. For those suffering from anxiety, depression, and PTSD, these rewards provide a benefit that standard treatment does not seem to offer. Those who use illegal drugs or alcohol and undergo treatment can also reduce their other addictive behaviors, such as cigarette use. Finally, those who have suffered multiple relapses still show more positive outcomes when earning rewards than those who simply stay out of legal trouble through the end of their treatment.
Contingency Management and Shame Culture
Sadly, many people in society see addiction as a sign of weakness. The concept that people can overcome addiction with willpower is both incorrect and destructive. Worse, households that use shaming to control behavior can push people toward anxious thoughts, depression, and drug use as a form of self-medication.
The general population often struggles to understand the difficulties experienced by those with substance use disorders. They have never experienced the changes to the brain that are caused by drugs. Therefore, people often look down on those suffering from addiction.
Many in the grip of addiction continue to function until the fragile structure around them falls apart. An addict may be able to keep a household going, keep a job, and even pay the bills. On the other hand, an active alcoholic may be arrested for DUI or hurt someone in a wreck before the illness is diagnosed and addressed. The outside world may well focus on the punishment for criminal behavior instead of treatment for a disease.
Because much of our culture shames addicts, the inability to understand just how much work has to go into a successful recovery can leave recovering addicts feeling like a burden. Overcoming addiction is a 24-hour-a-day job. You have to retrain your brain and rebuild your body while the cravings work to distract you. The ability to treat your brain to a different reward, such as the hope of a contingency management token, can be incredibly helpful.
Dr. Wakim is a board-certified psychiatrist with a passion for and expertise in addiction, mood disorders, trauma-related disorders and the subspecialty of interventional psychiatry. He obtained his medical degree from West Virginia University where he also completed his residency training, finishing as chief resident. Dr. Wakim co-founded and served as the CEO of Transformations leading to a successful merger with Shore Capital in May 2021. He is purpose driven towards improving the standard of and removing stigma related to behavioral healthcare. Dr. Wakim enjoys golf, traveling and time spent with his two dogs, Lulu and Rayna.
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