Practical Application of
Contingency Management
Michael J. McCann, MA
Matrix Institute on Addictions
Elements of Treatment:
Information, Persuasion, and Medication

Information
– Matrix Model
– CBT
– 12-Step

Persuasion
– Motivational Interviewing
– Confrontation
– Contingency Management
Motivational Interventions
If you build it they will not
necessarily come.
 And, if they do come, they may not
come all of the time.
 Hence:

– Motivational Interviewing
– Contingency Management
Contingency Management (CM)

CM: application of reinforcement
contingencies to urine results or
behaviors (attendance in treatment;
completion of agreed upon activities).

Research consistently shows that it
works.
Contingency Management:
Overview
1.
2.
3.
Research findings
Application of CM in the Matrix
Institute NTP
Practical application of CM
Contingency Management:
Research Findings

Effective with wide variety of abused
substances
– Nicotine
– Alcohol
– Heroin
– Benzodiazepines
– Cocaine and Methamphetamine
Research Findings

Highlight efficacy

Raise questions about real-world
applicability
Contingency Management:
Steve Higgins, Ph.D.

Community Reinforcement Approach
(CRA)
– Marital Therapy
– Vocational Assistance
– Skills Training
– New social and recreational activities
– Antabuse

Vouchers ($977)
Contingency Management:
Higgins et al., 1993
– 24-week treatment
– 3 times per week urines
– Conditions
• Standard treatment
• CRA plus vouchers
Contingency Management:
Higgins et al., 1994
– 24-week treatment
– 3 times per week urines
– Conditions
• CRA only
• CRA plus vouchers
Contingency Management:
Higgins et al., 1993
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Standard Treatment
CRA & CM
68%
58%
42%
11%
Completed Treatment
11%
8 weeks continuous
abstinence
5%
16 weeks continuous
abstinence
Contingency Management:
Higgins et al., 1994
– How much of CRA effect is CM?
– 24-week treatment
– 3 times per week urines
– Conditions
• CRA only
• CRA plus vouchers
Contingency Management:
Higgins et al., 1994
100%
90%
80%
CRA
CRA & CM
75%
70%
60%
50%
55%
40%
40%
30%
20%
15%
10%
0%
Completed Treatment
8 weeks continuous abstinence
Contingency Management:
Rawson et al., 2002

Cognitive-Behavioral Treatment vs
CM
– Cocaine users
– 16 weeks
– 3 visits per week
Contingency Management:
Rawson et al., 2002

Cognitive-behavioral Treatment
(CBT)
– 90 minute groups
– Cognitive/behavioral
– Drug cessation
– Lifestyle change
– Relapse prevention
Contingency Management: Rawson
et al., 2002

Contingency Management
– Vouchers for stimulant-free urines
– Progressive schedule
– Bonuses for 3 consecutive clean ($10)
– Reset with 5 clean
– Total earnings possible: $1277
Contingency Management:
Rawson et al., 2002
Cocaine-using methadone patients
 Four conditions:

– CM
– CBT
– CBT & CM
– Methadone only
Cocaine-free Urine Samples During Study
Rawson et al., 2002
35
30.3
# cocaine-free
30
25
26.1
19.8
20
15
11
10
5
0
P<.001
CM>MM
CBT & CM>MM
CBT
CM
CBT & CM
MM
Percent Subjects Achieving 3 Consecutive
Weeks Cocaine-free
Rawson et al., 2002
% pts. 3-weeks cocaine free
70%
63%
57%
60%
50%
40%
40%
27%
30%
20%
10%
0%
P<.02
CM>MM
CBT & CM >MM
CBT
CM
CBT & CM
MM
Days used cocaine in past month
Rawson et al., 2002
15
# days used
12
MM
CM
CBT + CM
CBT
9
6
3
0
Baseline
Wk-17
Week 26: CM<MM; CBT<MM
Week 52: CBT<MM
Wk-26
Wk-52
CBT Group Attendance
Rawson et al., 2002
30
# sessions attended
24.7
25
20
17.9
15
10
5
0
P<.04
CBT
CBT & CM
Contingency Management in Treatment

Conclusion: CM works
Contingency Management in Treatment
• CM is not always popular with counselors.
• “Simply getting clean should be reward enough.”
• Other problems:
• Schedules are too complicated.
• Too expensive for the average clinic. The cost of
vouchers exceeds what some clinics are
reimbursed for a treatment episode.
CM in Practice in an NTP
Treatment enhancements (RP
groups, women’s groups, stimulant
groups, HIV and Hep-C education,
low cost CM)
 $5 per month for perfect group
attendance
 $5 per month for perfect medication
attendance

Perfect medication attendance
Pre-post contingencies, n=49
52%
55%
% perfect
50%
45%
40%
37%
35%
30%
25%
Pre-CM
P<.05
Post-CM
Perfect group attendance
Pre-post contingencies, n=49
71%
75%
% perfect
70%
65%
58%
60%
55%
50%
45%
40%
Pre-CM
P<.01
Post-CM
Perfect group attendance in patients
missing pre-CM, n=20
80%
65%
70%
% perfect
60%
50%
40%
30%
20%
10%
0%
0%
Pre-CM
Post-CM
% groups
Groups attended in patients missing
pre-CM, n=20
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
88%
58%
Pre-CM
P<.005
Post-CM
CM in an NTP: Conclusions

A simple, low cost CM intervention
can improve patient attendance in
groups and medication visits.
CM with Matrix Model Treatment
May improve engagement of new
patients
 May improve retention of patients
 May improve treatment outcomes

CM with Matrix Model Treatment

Challenges
– Must be simple
• Easy to track—Need to keep a record of
attendance
• Easy to figure rewards—no progressive
schedules, resets, etc.
• Little burden on the counselor
CM with Matrix Model Treatment

Challenges
– Must be inexpensive
• A less expensive method may be a bit less
effective, but an expensive method will
never be used.
• A little reward goes a long way especially
combined with praise and recognition
CM with Matrix Model Treatment:
Some examples
Food available for 10 minutes after
group starts
 Weekly reward for patients who
attend all groups each week
 Monthly reward for patients who
attend all groups each month

CM with Matrix Model Treatment:
Some examples
Raffles vs guaranteed reinforcement
 Certificates, plaques, food, goods,
money, etc.
 Combine with social reinforcement

Conclusions
CM can be effectively used in clinical
settings
 Low cost reinforcers can be effective
 Simple schedules can be effective
 Increased attendance can offset cost
with fee-for-service billing
