By Carol-Ann Getty
What is Contingency Management?
Contingency management (CM) has a long history of application in both basic and clinical research and a strong theoretical background in behavioural sciences and operant conditioning. CM interventions involve the systematic application of positive reinforcement. Positive reinforcement is a form of operant conditioning which ‘reinforces’ desirable behaviours that are congruent with treatment goals by providing a reward (e.g. monetary rewards or vouchers) which is contingent upon demonstration that the behaviour has occurred. The approach has been used to promote changes in drug use and other therapeutic goals, such as abstinence or attendance at clinic appointments. CM interventions should be based on seven key principles (see below). Evidence suggests that adherence to these principles increases the likelihood that the positive reinforcement being offered will encourage the desired behaviour, thereby addressing our disciplines central goal of solving problems of social importance.
The seven principles of Contingency Management
- Target behaviour: must be problematic and in need of change but also observable and measurable
- Target population: select the patient group who exhibit the target behaviour and are most at need or who are particularly vulnerable
- Choice of reinforcer/incentive: must be perceived as desirable to each patient to be effective
- Magnitude of incentive: the magnitude of reinforcement needed to sustain change may differ for different behaviour targets
- Frequency of the incentive distribution: behaviours might need to be reinforced frequently initially until they are well established
- Timing of the distribution of the reinforcement: reinforcement needs to follow the exhibition of the target behaviour as closely as possible
- Duration of the reinforcement intervention: most effective when used long-term, or at least until naturally occurring reinforcers that support their recovery are established.
Contingency Management in UK substance use treatment services
The integration of Contingency Management in UK substance use treatment services to promote therapeutic progress and positive treatment outcomes is recommended by the UK National Institute for Health and Care Excellence (NICE). Although, the implementation of CM in the UK has been limited, recent research has demonstrated evidence for the effectiveness of incentive programmes to improve completion of hepatitis B vaccinations in people undergoing treatment for heroin dependence (Weaver et al., 2014). Current research is also being conducted to assess the impact of CM incentives in promoting abstinence from opiates or attendance at treatment sessions (Metrebian et al., 2018). The impressive body of evidence demonstrating the efficacy of these interventions in promoting desirable behaviour change in those affected by substance misuse disorders is what awards CM the recognition of being a ‘behaviour analysis success story’ (Dallery et al., 2019). However, while we know this is true at a research level, successful implementation in clinical settings is not so straightforward. CM interventions require satisfaction of the seven principles of CM (as outlined above), meaning behaviour must be frequently monitored to detect and verify behaviour change and the delivery of the reinforcement must be without any significant delay (Higgins & Silverman., 2008). These requirements have an impact on the ease of implementing CM into routine practice, particularly in settings with already restricted finances and resources (Rash, Stitzer & Weinstock., 2017; Petry., 2010).
What is the rationale for using mobile telephones to deliver CM?
Evidence-based treatments (such as opioid substitution treatment) are not achieving their full benefit due to poor adherence and high levels of drop out among patients. Identifying effective interventions that address these problems but that are also scalable and accessible to all is an important priority. Delivering CM remotely using mobile telephones has the potential to provide greater accessibility to those hard-to-treat substance using individuals or those who might not normally access treatment services. It also enables services to stay in contact with patients over a longer period of time to support their recovery (Hämäläinen et al., 2018). Delivering CM electronically also enables clinicians to continuously or frequently monitor behaviours that are rarely a target of CM interventions as they require frequent testing, such as alcohol consumption due to the rapid metabolisation rate or daily medication adherence to opiate substitution treatment.
Researchers in the USA have made considerable advances in combining CM interventions with technological applications and believe this might offer a feasible way in which behaviour change interventions can be delivered for the treatment of substance use disorders (Dallery & Raiff., 2011). Here, in the UK, researchers are currently assessing the feasibility of mobile telephone delivered CM to encourage adherence with supervised consumption of methadone in community pharmacies (Metrebian et al., 2019). Technology based CM does not only lessen the burden on clinical staff, but it also ensures the intervention is delivered consistently, satisfying the key principles of CM each and every time it is delivered. Given these advantages and the increasing use of mobile technologies, there is growing interest in utilising mobile telephones to deliver CM.
How can mobile telephones deliver CM?
Technology can be used to monitor behaviour to verify behaviour change or achievement of the target behaviours. Most commonly, research participants are required to take videos of themselves completing a carbon monoxide or alcohol breath concentration test to monitor smoking and alcohol consumption respectively. Videos are electronically submitted to the researchers who verify satisfaction of the target behaviour. Secondly, technology can be used to remotely deliver reinforcement upon verification that desirable behaviour change and the contingency has been achieved. Typically, this is in the form of a text message of verbal praise, accompanied by details of financial earnings. While the majority of existing studies mailed earnings to participants, a novel approach now enables financial rewards to be delivered electronically using reloadable credit cards provided by the research team. As previously outlined, these two factors of monitoring behaviour and delivering immediate recognition are key in satisfying the principles of positive reinforcement.
Is mobile-telephone CM effective?
In a recent meta-analysis to examine the evidence for the effectiveness of mobile telephone-delivered CM interventions to promote abstinence, medication adherence and treatment engagement among individuals with substance use disorders, Getty et al., (2019) found that mobile telephone-delivered CM performed significantly better than control conditions. This review was the first to assess the evidence for the effectiveness of mobile telephone-delivered contingency. It included studies that employed randomised controlled or within-subject designs and drew on data from three outcomes of clinical relevance, including; Percentage of Negative samples (PNS), Longest Duration Abstinent (LDA) and Quit Rate (QR). The review highlights how research in this area is vastly limited with interventions having only targeted alcohol abstinence, smoking cessation and medication adherence.
A promising future for mobile-telephone CM?
The review explored the ways in which mobile telephones can be used to deliver CM interventions to target a range of behaviours, and although it presents optimistic and encouraging findings, this novel approach is still in its infancy. Currently, the literature is dominated by studies targeting tobacco and alcohol use in adults not in treatment for substance use disorders, with no research evaluating its impact in reducing drug use behaviours. Given the vast technological developments and advances being made to monitor behaviours, we believe more effective and accurate monitoring equipment will enable us to target drug use in the near future.
Carol-Ann Getty is a PhD student at King’s College London, researching how Contingency Management can be delivered by mobile telephones to bring about positive behaviour change in individuals with substance use disorders.
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