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A comprehensive guide to the application of contingency management procedures in clinical settings

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Abstract

Controlled clinical research has demonstrated the efficacy of contingency management procedures in treating substance use disorders. Now is the time to begin introducing these procedures into standard clinical practice. This article reviews the rationale of contingency management interventions and provides a review of representative scientific work in the area. It also discusses behaviors that can be modified, reinforcers that can be used, and behavioral principles that can be adapted to improve outcomes. This paper provides practical advice and a guideline for clinicians and researchers to use when designing and administering contingency management interventions. The recommendations are based on empirically validated manipulations. Areas in which more research is needed are suggested as well.

Introduction

A variety of clinical trials have demonstrated the efficacy of contingency management (CM) interventions in retaining substance abusers in treatment and fostering drug abstinence. CM interventions often include three basic tenets (e.g. Higgins et al., 1994b). First, the clinician arranges the environment such that target behaviors (e.g. drug abstinence, clinic attendance, medication compliance, other behaviors) are readily detected. Second, tangible reinforcers are provided when the target behavior is demonstrated, and third, incentives are withheld when the target behavior does not occur. Despite compelling evidence regarding their efficacy and the wide acceptability and applicability of these procedures, CM approaches are rarely implemented into treatment programs. This paper briefly describes some research demonstrating the efficacy of CM procedures and suggests practical applications for use in community-based settings.

Section snippets

Efficacy of CM

This section provides a brief review of the beneficial effects of CM procedures.

Drug abstinence

The central premise of substance abuse treatment is to reduce drug use, and this is the behavior of focus of most CM trials. In designing CM interventions that reinforce drug abstinence, the goal is to detect all instances of use of the target drug. Thus, CM studies typically monitor drug use 2–3 times per week, because most urine testing systems can detect drug use over this period (e.g. Saxon et al., 1988, Cone and Dickerson, 1992). When clients submit specimens negative for the targeted

Reinforcers to use

CM procedures can use a variety of reinforcers, many of which are commonly used in, or readily adaptable to, standard clinic settings. Pros and cons of each reinforcer are discussed, with an emphasis on reinforcers that can be applied in typical clinic settings.

Special considerations

When designing and implementing CM procedures, variables central to learning theory and behavioral analysis should be considered, as described below. Although many of these have not been evaluated empirically in terms of reducing drug use, they have been shown important in altering behavior in other contexts.

Step 1: choose a behavior

In designing a CM treatment, first pinpoint the specific behavior you want to alter. Choose one that can be quantified objectively and occurs frequently. A target behavior may be cocaine abstinence, increasing social activities or medication compliance, or retention in aftercare. Although all these behaviors can be altered, be careful to not ask for too much at once. High expectations (abstinence from all drugs, compliance with all clinic rules) may result in clients not earning any

Summary

This paper has reviewed briefly the efficacy of CM, behaviors that can be modified, and reinforcers that can be used. It also provided suggestions for designing CM procedures that encorporate behavioral principles. Most treatment settings employ many aspects of CM techniques already. For example, many clinicians monitor urine specimens for drug use, work with clients on setting treatment goals, address inappropriate clinic behavior, and encourage medication compliance. Drug use and treatment

Acknowledgements

Preparation of this manuscript was supported by NIH grants R29-DA12056 and P50-AA03510. Dr Henry Kranzler is thanked for helpful comments on an earlier version of this manuscript. Portions of this paper were presented at the American Academy of Addiction Psychiatry in Amelia Island, FL, 1998.

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