We experience positive reinforcement in everyday life while raising children, in our careers, and when training our pets. Positive reinforcement helps us reach our goals, grow, and live happier lives through behavior modification. When we lack motivation, incentives can help us move forward. In the behavioral health care setting, we can use contingency management techniques to help patients curb illicit behaviors and habits such as methamphetamine and cocaine use and the misuse of prescription medications such as opioids and benzodiazepines.

Contingency management (CM) is one of the most enduring approaches to behavior modification. The method is an especially effective treatment for drug and alcohol dependence. Despite the benefits, CM remains an underutilized behavioral treatment for several reasons. But before we get into those — and how you can use CM in your practice — it's important to thoroughly define what comprises contingency management.

What Is Contingency Management?

CM is a behavioral modification strategy (or a behavioral intervention) based on the concept of operant conditioning, which posits that humans will adjust their behavior to reap rewards or avoid punishment.

B.F. Skinner first described operant conditioning as a behavioral method of learning in the 1960s. According to the theory of operant conditioning, behaviors are formed by their consequences, both positive and negative. Positive behaviors or choices that are rewarded increase over time, while the actions that produce unpleasant experiences decrease.

In contrast to operant conditioning, contingency management treatment promotes clinically relevant behavior change exclusively through positive reinforcement. CM employs a unique combination of accountability measures and incentives that can supercharge a patient’s motivation for behavioral change. Evidence points to CM’s effectiveness in treating a broad range of behavioral health disorders, including alcohol dependence, methamphetamine addiction, cocaine dependence, and prescription opioid and benzodiazepine misuse.

In addition to abstinence from substance use, CM is helpful in reinforcing positive practices such as completing methadone maintenance, treatment attendance, and medication compliance. Contingency management is also helpful in terms of pro-health behaviors like exercise, weight loss, and tobacco cessation. 

Contingency Management as an Adjunct Treatment

Methamphetamine and cocaine dependence can be some of the hardest addictions to overcome, but research indicates that when given incentives for abstaining from drugs, patients are more likely to stick with their outpatient treatment programs, thus preventing relapse for more extended periods. 

CM is regarded as an important component in successful evidence-based treatment plans for drug use. However, contingency management interventions aren't meant to take the place of other programming modalities. Instead, CM should supplement your behavioral approach. Treatment providers often use CM alongside other strategies, such as cognitive behavioral therapy (CBT), medication, and peer support.

According to research, some of the most effective treatment combinations for drug use include methadone treatment and psychosocial therapy with CM. This behavioral approach has been very successful in keeping patients in treatment longer while promoting drug abstinence. Other research shows that encouraging exercise is associated with better outcomes when combined with CM to treat patients with substance use disorder.

There is no magic combination of contingency management interventions nor is there a one-size-fits-all plan. Matching therapy environments, behavioral treatments, and resources to an individual's specific treatment goals and requirements are crucial to their success in recovery. 

How Contingency Management Drives Patient Engagement 

CM gives patients the motivation they need to make positive changes. Any time a patient is empowered to take responsibility for their own health outcomes, they become more engaged. In turn, engagement may help patients adhere to their treatment plan for extended periods — and longer-term abstinence from drugs or alcohol can be a reliable predictor of sustained recovery.

Furthermore, CM can be an effective tool for showing individuals that they are capable of changing their behavior when sufficiently motivated. Success helps patients overcome feelings of guilt or low self-esteem by fostering confidence over time. 

Use of CM: Barriers and Opportunities

Monetary incentive payments in the form of cash or cash equivalents provide an excellent source of motivation. However, the idea of giving cash to patients who are receiving drug abuse treatment is not without controversy. In some cases, practitioners worry that their patients will make superficial and temporary changes rather than sincere, long-lasting ones.

It's essential to keep in mind that even if individuals change their behavior for the incentive, they are still doing so voluntarily. Any behavioral modifications made by patients can increase their likelihood of a successful recovery. Studies have shown that patients who previously received contingency management continue to benefit even after the prize incentive is no longer available. 

Another concern is whether CM violates federal law. Legislation against kickbacks prohibits providing anything of value for the purpose of obtaining or keeping a patient's business. It’s easy to conflate kickbacks with motivational incentives. To clarify the matter, the Office of Inspector General (OIG) issued Advisory Opinion No. 22-04 concerning CM incentive programs. 

Note: This explanation is provided for context and general information and is not legal advice.

The OIG recommends that contingency management incentives be provided through a third party. In addition to prize incentives, patients should also have access to digital tools that support better outcomes for patients with substance use disorders. In other words, the incentive plan should be part of a larger digital patient engagement strategy. 

The behavioral health care organization must pay for the incentives. That is to say, neither the patient, their insurance company, nor any other third-party payers are responsible for funding or paying for the incentives. To be eligible for incentives, patients must demonstrate having achieved specific behavioral health objectives and treatment goals. 

The OIG also recommends that contingency management programs include the following features:

• Appointment reminders
• Medication reminders
• Medication adherence checks
• Tests for drugs, alcohol, and/or tobacco
• Cognitive behavioral therapy (CBT)
• Surveys and assessments
• Certified recovery coach
• Family support 
• Moderated virtual support groups that meet daily

The guidelines are a lot to take in. When the stakes are this high, you need a technology partner that checks all of the boxes. ContinuumCloud’s patient engagement app powered by CaredFor provides the digital infrastructure and all the necessary tools to run a successful, cost-effective, and compliant CM program. 

The CaredFor patient engagement app is highly configurable and supports all branches of behavioral health care, including inpatient and outpatient drug abuse and addiction treatment centers, psychiatry practices, mental health clinics, human services, and more. 

The Versatility of Digital Contingency Management

In the past, clinicians provided contingency management in person so they could verify drug abstinence by having the patient submit a urine sample. The same modern technologies that make remote behavioral health care and programming possible can also be used for incentive delivery and even drug testing.

According to the OIG, CM programs should feature individual and group therapy, which helps enforce positive behavioral change while encouraging abstinence and a drug-free lifestyle. The CaredFor app makes it easy to organize groups into online communities that target different high-risk behaviors.

The CaredFor app has built-in contingency management features that let patients and alumni earn points and rewards for interacting with the platform. Some examples of reward activities could be setting and reaching behavioral treatment goals, maintaining connections, attending therapy, answering surveys, and supporting or encouraging others on the platform. 

Reacting to a post, making a comment, and establishing and achieving milestones are other ways to gain experience points. When the patient earns enough points, they can be redeemed for digital prizes. 

As the administrator, it’s up to you to define the types of prizes available and determine which behaviors to reinforce by triggering a reward. Depending on your budget, you may offer prizes with monetary value such as gift cards and vouchers or you may opt for digital “tokens of recognition” such as awards, stickers, and certificates.

Make Contingency Management Part of Your Digital Engagement Strategy

Research has shown that treatment options based on contingency management principles are effective. CM entails offering patients awards, recognition, and sometimes monetary rewards to reinforce positive behavior changes like drug abstinence. There are certain rules you must follow and while the federal government provides ample guidance, it can be difficult to understand. But you don't need to let legalese stand between you and CM as a strategy for treating patients. This is where ContinuumCloud comes in.

The CaredFor app was created to provide behavioral health patients immediate access to services and support networks while in treatment and in the community. In addition to being a patient engagement platform, the CaredFor app from ContinuumCloud also provides a fully compliant contingency management framework. Through the platform, you’ll be able to assist patients in creating long-term connections with your program to maximize engagement, improve retention, and deliver services efficiently.

To learn more about the CaredFor app and how it can help your patients reach their goals, connect with us today.