Contingency management interventions: from research to practice.

Abstract

Behavioral interventions have enjoyed widespread use in the treatment of a variety of psychiatric conditions, including autism (1), conduct disorder (2), developmental disorders (3), eating disorders (4), and even schizophrenia (5). These techniques are based upon the principles of rearranging the environment to reinforce appropriate behavioral patterns while providing negative reinforcement for inappropriate behaviors. Similar procedures have been applied to substance-abusing populations, and these interventions have been termed contingency management. In the treatment of substance use disorders, contingency management techniques have demonstrated efficacy in retaining substance-abusing clients in treatment, promoting drug abstinence, and encouraging appropriate behaviors (see reference 6 for review). These treatments are based on three general behavioral principles: 1) frequent monitoring of the target behavior; 2) provision of tangible, positive reinforcers when the target behavior occurs; and 3) removal of the reinforcer when the target behavior does not occur. In a series of elegantly designed clinical trials, Higgins et al. (7–10) demonstrated the efficacy of contingency management in treating cocaine dependence. Despite their efficacy in specialized research programs, contingency management approaches have been criticized for their cost and putative lack of applicability in community-based settings. In the studies conducted by Higgins and colleagues, for example, clients earned vouchers that were exchangeable for retail goods and services in excess of $1,000. Non-research-based clinics are unlikely to have the funds to support voucher programs, and less expensive contingency management approaches may be necessary for adaptation in community-based settings. Moreover, research studies necessitate use of specific protocols that are strictly enforced across all clients, while clinical practice often employs a more individualized approach toward therapy. When applied in community-based programs, contingency management interventions are likely to be tailored to unique client characteristics and issues. To illustrate the similarities and divergences of contingency management when applied across settings and clients, we detail here three case reports. We selected cases from three distinct community-based treatment programs that varied along a number of dimensions. The interventions varied with respect to the reinforcers used and the behaviors targeted for reinforcement. Case 1 describes a subject with cocaine-induced psychotic episodes on a regimen of methadone maintenance who participated in a contingency management study that reinforced abstinence from opioids and cocaine by using the chance to win prizes as the reinforcer. Case 2 involves an HIV-positive subject with cocaine dependence and intermittent explos i ve d i s o rd e r f o r w h o m p r i z e reinforcements were linked to group attendance and the accomplishing of individually tailored goals. Finally, case 3 descr ibes an individu al with cocaine dependence and paranoid schizophrenia who was chronically misusing psychiatric emergency room services. A contingency management plan was implemented that provided portions of his disability payments contingent upon drug abstinence, medication compliance, and appropriate use of therapeutic services. These examples illustrate the use of contingency management in sequentially less structured settings and involving less start-up resources for application.