Contingency management (CM) is a behavioral therapy technique that encourages beneficial behaviors by giving rewards or positive reinforcement.
CM incentivizes certain behaviors and discourages undesired ones. By providing tangible rewards for positive behaviors, CM aims to alter behavior patterns.
Psychologists sometimes use CM to help people with substance use disorder or addiction. There are differing opinions on its effectiveness and whether it is a suitable long-term strategy.
In this article, we discuss what CM is, the theory behind it, examples of CM, and whether it works, and we address some controversies surrounding it.
Contingency management (CM) is a behavior modification strategy. Practitioners reinforce desirable behaviors with incentives such as cash, a voucher, or another reward.
CM may also discourage unhelpful behaviors by enforcing consequences if a person does not adhere to their treatment goals, such as by withholding rewards or privileges.
CM comes from the concept of operant conditioning, which is a psychological theory about how people learn voluntary behaviors.
The theory states that stimuli can either reinforce a behavior or punish it. People can learn to adjust their behavior to gain something pleasant or avoid something unpleasant.
There are
- positive reinforcement
- negative reinforcement
- positive punishment
- negative punishment
In this framework, the words “positive” and “negative” do not mean “good” or “bad.” Instead, they refer to whether a person is adding a stimulus or taking it away from a situation.
The table below summarizes each possible scenario:
| Positive | Negative | |
|---|---|---|
| Reinforcement | adds a reward when a person behaves in a desirable way | removes a punishment when a person behaves in a desirable way |
| Punishment | adds a punishment when a person behaves in an undesirable way | removes a reward when a person behaves in an undesirable way |
Of these approaches, positive reinforcement works more quickly and effectively than punishment. CM primarily uses positive reinforcement.
The main use of CM is for the treatment of substance misuse or other addictions, such as gambling addiction. Practitioners may provide rewards such as cash, vouchers, or other privileges when a person:
- attends a clinic or support group
- hands in a drug-free urine sample
- hits certain milestones in their recovery
- takes medications that help their recovery
There is also some evidence that CM may help encourage people to undergo testing and treatment for HIV, and help people with depressive symptoms quit smoking, although more research is necessary.
Other therapies that incorporate operant conditioning more broadly include:
- Parenting programs:
Several parenting programs teach operant conditioning as a way of managing challenging behavior in children. These include the positive parenting program and parent-child interaction therapy. - Child therapy: Mental health professionals may use aspects of operant conditioning when helping children and adolescents in individual therapy.
- Applied behavioral analysis (ABA): Practitioners mainly use ABA as an intervention for autistic children. However, it is controversial. A 2019 study suggests that prolonged ABA is potentially harmful. Activists argue that, as autism is not a behavioral or mental disorder, it does not require this type of therapy.
Outside of medical contexts, operant conditioning may also inform how teachers, managers, and coaches work with people to achieve certain goals.
For substance misuse, CM appears to be effective.
For example, a 2024 study found that after a 4-week period of abstinence, 68.4% of participants wanted to continue abstaining from cannabis or reduce their usage afterward.
The participants consisted of 220 young people who used cannabis but were not seeking treatment. Those who set goals to remain abstinent had greater decreases in cannabis use after another 4 weeks than those who did not.
This change in attitude suggests that CM has the ability to increase intrinsic motivation as well as extrinsic motivation. Intrinsic motivation is the impetus to do something that comes from one’s own opinions or values rather than external pressures.
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CM may be most effective when a healthcare professional integrates it into a comprehensive treatment plan including other approaches, such as cognitive behavioral therapy.
Despite its effectiveness, contingency management is not without controversy. Several concerns include:
- Cost: The financial cost of providing incentives
can be substantial , raising questions about the sustainability and scalability of CM programs. - Ethical issues: Some argue that paying individuals to abstain from harmful behaviors is unethical or a form of bribery.
- Potential for manipulation: There is a potential risk that individuals might manipulate CM programs to receive rewards without genuine behavior change.
Some people may also question whether external rewards can truly result in long-term behavior change, particularly after those rewards are no longer present.
But research suggests that CM does lead to a higher likelihood of prolonged behavior change. Incentives may help people get through the most difficult part of their recovery, remind them how they felt before using a substance, or bring about other positive changes that provide their own motivation.
However, CM may not work or be accessible to everyone. Many factors influence addiction, such as:
- a person’s environment
- duration of treatment, with longer CM programs having a
higher likelihood of helping long-term - mental health
- genetics
Individuals living with substance use disorder or other forms of addiction may benefit from CM as part of their recovery. People can speak with a health professional about whether this option could be a good fit for them.
Healthcare professionals, including psychologists and addiction specialists, can also offer guidance on integrating CM into a broader therapeutic strategy.
Help is available
Seeking help for addiction may feel daunting or even scary, but several organizations can provide support.
If you believe that you or someone close to you is showing signs of addiction, you can contact the following organizations for immediate help and advice:
- Substance Abuse and Mental Health Services Administration (SAMHSA): 800-662-4357 (TTY: 800-487-4889)
- 988 Suicide & Crisis Lifeline: 988
Contingency management (CM) is a type of behavioral therapy that uses the principles of operant conditioning to encourage positive behavior changes.
It is particularly effective for treating substance misuse and addiction and may encourage other types of behavior modification, such as quitting smoking.
However, the approach is not without its controversies, particularly regarding ethical considerations and long-term sustainability.
When healthcare professionals use it appropriately and in combination with other therapeutic interventions, CM can offer significant benefits for individuals seeking to change their behavior.