Clinical Case Conference

Contingency Management Interventions:

From Research to Practice

Nancy M. Petry, Ph.D. settings. Moreover, research studies necessitate use of

specific protocols that are strictly enforced across all cli-
Ismene Petrakis, M.D. ents, while clinical practice often employs a more indi-
vidualized approach toward therapy. When applied in
Louis Trevisan, M.D. community-based programs, contingency management
interventions are likely to be tailored to unique client
George Wiredu, M.D. characteristics and issues.
To illustrate the similarities and divergences of contin-
Nashaat N. Boutros, M.D. gency management when applied across settings and cli-
ents, we detail here three case reports. We selected cases
Bonnie Martin, B.A. from three distinct community-based treatment programs
that varied along a number of dimensions. The interven-
Thomas R. Kosten, M.D. tions varied with respect to the reinforcers used and the
behaviors targeted for reinforcement. Case 1 describes a

B
subject with cocaine-induced psychotic episodes on a reg-
imen of methadone maintenance who participated in a
ehavioral interventions have enjoyed widespread use contingency management study that reinforced absti-
in the treatment of a variety of psychiatric conditions, in- nence from opioids and cocaine by using the chance to
cluding autism (1), conduct disorder (2), win prizes as the reinforcer. Case 2 in-
developmental disorders (3), eating disor- volves an HIV-positive subject with co-
ders (4), and even schizophrenia (5). These “The other addicts, caine dependence and intermittent explo-
techniques are based upon the principles of si ve disorder for whom prize
rearranging the environment to reinforce they see how I’ve reinforcements were linked to group at-
appropriate behavioral patterns while pro- changed, and they tendance and the accomplishing of indi-
viding negative reinforcement for inappro-
priate behaviors. Similar procedures have don’t believe it.... vidually tailored goals. Finally, case 3 de-
s c r ib es a n i n d i vi du a l wi th c o c a i n e
been applied to substance-abusing popula- I’ve become a dependence and paranoid schizophrenia
tions, and these interventions have been
termed contingency management. beautiful person.” who was chronically misusing psychiatric
emergency room services. A contingency
In the treatment of substance use disor- management plan was implemented that
ders, contingency management techniques have demon- provided portions of his disability payments contingent
strated efficacy in retaining substance-abusing clients in upon drug abstinence, medication compliance, and ap-
treatment, promoting drug abstinence, and encouraging propriate use of therapeutic services. These examples il-
appropriate behaviors (see reference 6 for review). These lustrate the use of contingency management in sequen-
treatments are based on three general behavioral princi- tially less structured settings and involving less start-up
ples: 1) frequent monitoring of the target behavior; 2) pro- resources for application.
vision of tangible, positive reinforcers when the target be-
havior occurs; and 3) removal of the reinforcer when the
target behavior does not occur. In a series of elegantly de- Case 1
signed clinical trials, Higgins et al. (7–10) demonstrated
the efficacy of contingency management in treating co- Initial Assessment
caine dependence. Ms. A was a 45-year-old Caucasian woman diagnosed
Despite their efficacy in specialized research programs, with heroin and cocaine dependence, bipolar disorder,
contingency management approaches have been criti- antisocial personality disorder, and cocaine-induced psy-
cized for their cost and putative lack of applicability in chotic episodes. She had a long history of prostitution
community-based settings. In the studies conducted by and sharing injection equipment. She had contracted
HIV 5 years ago and was awarded a psychiatric disability
Higgins and colleagues, for example, clients earned
at that time.
vouchers that were exchangeable for retail goods and ser-
Ms. A had been on a regimen of methadone mainte-
vices in excess of $1,000. Non-research-based clinics are nance for about 2 years. Despite dose increases up to
unlikely to have the funds to support voucher programs, 120 mg/day, she continued using heroin at the rate of
and less expensive contingency management approaches one to 15 bags per day as well as up to three to four
may be necessary for adaptation in community-based dime bags per day of cocaine. After cessation of a co-

694 Am J Psychiatry 158:5, May 2001

 CLINICAL CASE CONFERENCE

caine run, Ms. A experienced tactile and visual hallucina- Contingency Management Plan
tions characterized by “bugs crawling around in my
skin.” She mutilated herself during severe episodes and Following discharge from the psychiatric unit, Ms. A
brought in quantities of her skin to show the “bugs” to was offered participation in our NIDA-funded study eval-
her therapist. uating lower-cost contingency management treatment
Ms. A had been hospitalized four times for cocaine-in- (e.g., reference 11) for cocaine-abusing methadone pa-
duced psychotic episodes. Following an 11-day stay in an tients. As part of participation in this study, Ms. A agreed
inpatient dual diagnosis program subsequent to another to submit staff-observed urine samples on 2–3 randomly
cocaine-induced psychotic episode, Ms. A was referred to selected days each week for 12 weeks. She was told that
our ongoing study of contingency management inter- she had a 50% chance of receiving standard methadone
ventions for methadone-maintained, cocaine-depen- treatment plus frequent urine sample testing or stan-
dent outpatients. dard treatment along with a contingency management
intervention. She provided written informed consent, as
Developmental History approved by the university’s institutional review board.
Ms. A was randomly assigned to the contingency man-
Ms. A had two brothers, both of whom were drug agement condition. In this condition, she earned one
abusers. Alcohol abuse was present in both her parents’ draw from a bowl for every urine specimen that she sub-
families, and she reported physical and sexual abuse mitted that was clean from cocaine or opioids and four
since the age of 3. She dropped out of school at age 16 draws for every specimen that was clean from both sub-
and had her first of two children 1 year later. She has had stances. In addition, for each week of consecutive absti-
little contact with her 28- and 13-year-old sons, who are nence from both cocaine and opioids, she earned bonus
being raised by their fathers. draws. The first week of consecutive cocaine and opioid
Ms. A’s substance abuse began at age 13, when she abstinence resulted in five bonus draws, the second
started using alcohol and marijuana. Cocaine abuse be- week resulted in six bonus draws, the third week seven,
gan in her early 20s, followed shortly by heroin abuse and so on. In total, Ms. A could earn about 200 draws if
and dependence. Since her mid 20s, Ms. A had used her- she maintained abstinence throughout the 12-week
oin and cocaine intravenously at the rate of 15 bags of study.
heroin and three to four dime bags of cocaine daily. Her The bowl contained 250 slips of paper. Half of them
drug use resulted in several emergency room visits for said “Good job” but did not result in a prize. Other slips
drug overdoses, multiple detoxifications, and three pre- stated “small prize” (N=109), “large prize” (N=15), or
vious methadone treatments, as well as numerous psy- “jumbo prize” (N=1). Slips were replaced after each
chiatric hospitalizations for suicidality and cocaine-in- drawing so that probabilities remained constant. A lock-
duced psychotic episodes. able prize cabinet was kept onsite in which a variety of
Ms. A also had an extensive legal history, including small prizes (socks, lipstick, nail polish, bus tokens, $1
convictions for drug charges, forgery, burglary, prostitu- gift certificates to McDonald’s or Dunkin’ Donuts, and
tion, and parole violations. She reported two incarcera- food items), large prizes (sweatshirts, Walkmans,
tions, one related to prostitution and the other for bur- watches, and gift certificates to book and record stores),
glary. She was on probation at the initiation of the and jumbo prizes (VCRs, televisions, and boom boxes)
contingency management study. were kept. When a prize slip was drawn, Ms. A could
With the exception of HIV, Ms. A’s medical history was choose from items available in that category. All prizes
nonremarkable. She attended an outpatient medical were purchased through funds from the research grant.
clinic for HIV but was not taking any medications for HIV
because she stated that they “mess up my liver.” She Clinical Course
sporadically attended an outpatient dual diagnosis pro-
Ms. A was excited about joining the research project
gram, from which she received several medications, in-
because she had heard about other clients winning
cluding fluoxetine (20 mg b.i.d.), gabapentin (300 mg
prizes. She submitted a urine sample negative for co-
q.i.d.), and doxepin (75 mg p.r.n.). She reported poor
caine and opioids her first week in the program, and she
compliance with the medications, especially during peri-
earned four drawings for this achievement. She won a
ods of heavy drug use. She frequently failed to attend
jumbo prize that day and selected a VCR. She was very
the methadone clinic, missing 11 doses in the 2-month
excited about the prizes, stating, “This is the best pro-
period before her most recent hospitalization. She had
gram in the world!” Ms. A maintained cocaine and opi-
not provided a urine specimen negative for both cocaine
oid abstinence for 4.5 consecutive weeks, earning bonus
and opioids before this inpatient stay.
drawings weekly.
Behaviors to Target In week 5, Ms. A experienced a relapse. She reported
using three bags of heroin and half of a dime bag of co-
Ms. A’s primary problem was her drug use, which was caine, and her urine sample was positive for both drugs.
associated with cocaine-induced psychosis and poor Although she admitted to no further drug use, she re-
compliance with psychiatric medications and with meth- mained opioid positive for over a week. During this
adone. Because her opioid and cocaine use were intri- week, she submitted cocaine-free specimens and there-
cately linked, it was thought that a contingency manage- fore earned one draw each time. She was remorseful
ment intervention that targeted abstinence from both about the relapse and was encouraged to regain absti-
drugs would improve her functioning. As she was already nence from both opioids and cocaine to reestablish her
maintained on a high methadone dose, methadone bonus draws. A week later, she submitted a urine speci-
dose adjustments were not made. men free from both drugs and began earning bonus

Am J Psychiatry 158:5, May 2001 695

CLINICAL CASE CONFERENCE

draws again. Throughout the rest of the 12 weeks, Ms. A Case 2

submitted urine samples clean from both drugs.
In total, Ms. A earned 175 draws during treatment. In Initial Assessment
addition to her one jumbo prize, Ms. A drew 67 small
Mr. B was a 35-year-old, divorced African American
prizes, and she selected gift certificates to Dunkin’ Do-
man with alcohol and cocaine dependence and intermit-
nuts and McDonald’s (36 times), socks and hosiery (17
tent explosive disorder. He was diagnosed with HIV in
times), food and drink items (nine times), costume jew-
1991.
elry and makeup (four times), and bubble bath (one
Since 1996, Mr. B had attended an HIV community
time). She also won 12 large prizes and selected a watch,
drop-in program about three to four times per week for
a Walkman, a camera, a purse, a travel bag, a curling
meals, clothing, and recreational activities. During his
iron, a jogging suit, a collectible box, two pot and pan
visits to the clinic, he would engage in heated arguments
sets, mixing bowls, and flatware. In total, these prizes
with other clients and staff. These arguments occurred
were purchased for $309.
on a weekly or more frequent basis. He would often ap-
During the study, Ms. A never missed a day of metha-
pear at the clinic intoxicated as well. On numerous occa-
done treatment, regularly attended group sessions, and
sions, Mr. B was formally written up by the program’s di-
honored all her individual counseling sessions at the
rector for arguments, intoxication, drug dealing, and
clinic. She was compliant with her psychiatry appoint-
fraud. For these offenses, he had been asked to leave the
ments and medications and experienced no psychotic
clinic several times, once for an entire year.
episodes during the program. Ms. A expressed enthusi-
Despite the fact that his drug use and impulsive behav-
asm for the project and encouraged other clients to join
iors resulted in a variety of medical, legal, social, and
the study. She was pleased with the prizes and stated,
employment problems, Mr. B had never received any
“Having good stuff in my apartment and new clothes
psychiatric or substance abuse treatment. Individual
makes me feel better about myself. When I feel good
case management sessions, groups focusing on medica-
about me, I don’t want to use cocaine.”
tion compliance, and individual and group substance
At 6-month follow-up, Ms. A had experienced only one abuse treatment were all offered free of charge onsite at
drug use lapse. She self-reported use of two bags of her- the HIV drop-in program, but Mr. B had never attended
oin and half of a dime bag of cocaine about 3 months af- any of these programs. He likewise refused to receive
ter the contingency management treatment ended. Her any treatment offsite, with the exception of occasional
urine sample results confirmed drug use at that time, medical visits for HIV. He was noncompliant with HIV
but her other clinic samples were drug-free. She began medication at the onset of the contingency management
volunteering at a local shelter and was taken off of pro- demonstration project.
bation. On a Quality of Life Inventory (12), Ms. A’s scores
increased from –2.2 at intake to the contingency man- Developmental History
agement study to –0.83 and –0.45 during treatment;
they rose to 1.46 posttreatment. At the time of this re- Mr. B had three brothers, all of whom had drug and al-
port, she had missed only 1 day of methadone treat- cohol problems and two of whom had been diagnosed
ment in over 6 months and was being considered for with intermittent explosive disorder. Both his mother
take-home privileges. and his father had problems with alcohol, although he
did not report any other psychiatric problems in his fam-
Review and Comments ily of origin. He came in for psychiatric treatment twice
in his lifetime for “severe anger management problems,”
This contingency management intervention led to a va- but he never returned following the intake evaluations.
riety of beneficial effects that extended beyond reducing Mr. B had five children with four different women. The
opioid and cocaine use. The subject became more compli- children ranged in age from 8 to 21 years; all were being
ant with methadone and psychiatric medications, and her raised by their mothers. Mr. B reported on-and-off rela-
quality of life improved on a variety of dimensions. tionships with his children that were marred by frequent
Nevertheless, the two lapses to drug use are a cause for conflicts with them and their mothers.
Mr. B began abusing alcohol and marijuana at age 18
concern. Although this subject was able to reinstate absti-
and cocaine at age 26. He had never received substance
nence, standard treatment does not provide frequent drug abuse treatment, and he reported no periods of absti-
monitoring or tangible reinforcement for abstinence. Spo- nence except during brief incarcerations. Mr. B was ar-
radic drug use without the benefits of the contingency rested on drug charges twice, once serving 3 months in
management program may result in a relapse, especially if jail.
one becomes noncompliant with psychiatric medications. Mr. B worked as a carpenter but lost several jobs be-
Because this subject was enrolled in a research study, cause of his “attitude.” In the past 5 years, he had not
been able to hold down a part-time job for more than a
extension of the contingency management plan beyond 3
month or two at a time. Because of financial difficulties,
months was not possible. She may have benefited from an
he had no stable housing arrangements and was “living
individualized approach targeting other problem behav- with friends” at the time of implementation of the con-
iors, such as frequent monitoring and reinforcement for tingency management demonstration project.
compliance with psychiatric medications. When absti-
nent from drugs, she may be able to tolerate medications Behaviors to Target
for HIV. A contingency management plan reinforcing Mr. B represented one of many substance abusers who
compliance with HIV medication (13) may have further do not come in for formal treatment. Despite his lack of
improved outcomes. involvement in treatment, his frequent attendance at

696 Am J Psychiatry 158:5, May 2001

 CLINICAL CASE CONFERENCE

this drop-in program indicated that Mr. B was willing to earlier. In this way, the number of total draws per week
engage on some level, if only for food and social interac- (by all clients) was decreased from an average of 50 in
tions. Although he had multiple problems ranging from weeks 7–18 to an average of 21 in weeks 19–24. From
anger management to drug abuse, limited medical treat- week 25 on, a return to baseline conditions occurred,
ment for HIV, and housing and unemployment difficul- with no drawings or prizes in either the Tuesday or the
ties, these issues could not all be solved at once. Con- Thursday groups.
tingency management interventions work best when
discrete behaviors are targeted (14). It was felt that a Clinical Course
contingency management plan that targeted simple be-
During the baseline period, Mr. B was often in the rec-
haviors (such as attendance) would assist in engaging
reation room of the clinic when the substance abuse
this client in treatment and reducing some of his psycho-
groups met. He was invited to join, but he always re-
social problems.
fused, calling them “for idiots.” He first attended group
Contingency Management Plan during the third week of incentives, because “I saw peo-
ple come out with good stuff, and I wanted to get some
This contingency management demonstration project of them free prizes.”
was designed to enhance attendance at the substance During weeks 10–12, Mr. B came to groups weekly, but
abuse treatment groups held onsite on Tuesdays and only on incentive days—Tuesdays. When the incentive
Thursdays and to improve psychosocial functioning of day switched to Thursdays in weeks 13–15, he came only
clients. The groups focused on developing weekly action on Thursdays. Beginning in week 16, however, a marked
plans to accomplish individually tailored goals. For ex- change in his behavior and attitude occurred. Mr. B be-
ample, if a goal was sobriety, the client might agree to at- gan attending both incentive and nonincentive groups.
tend two Alcoholics Anonymous meetings in the upcom- When incentives were removed in week 25, he contin-
ing week, find a sponsor at a meeting, or enroll in an ued participating in groups twice weekly. He missed only
offsite substance abuse treatment program. If a goal was three sessions in a 4-month period, calling in advance
to obtain employment, the client might agree to write a each time to inform the counselor why he was unable to
resume or complete three job applications in the up- attend.
coming week. If a goal was to improve health, the client During his first week in the group, Mr. B identified two
might agree to attend a medical appointment or to goal areas: to get a part-time job and “work on my atti-
record the dates and times of medication consumed. tude.” He failed to get information from a temporary
Each week, clients selected two specific activities related work agency, but he did meet individually with a counse-
to their treatment goals, and they reported back on their lor to discuss his problems with anger management. In
progress the subsequent week. Any client who was a his second week, he set these same activities again and
member of the drop-in clinic could attend the groups. successfully accomplished both of them. In his third
Membership at the clinic was free and open to anyone week, he began applying for jobs and identified finding
HIV positive. Over 90% of members of the clinic were sober housing as a new goal area; he filed paperwork for
drug dependent. disability housing that week. In his fourth week, he iden-
The first 6 weeks served as a baseline period, during tified clearing up legal problems as another goal area,
which attendance at groups and compliance with activi- and he attended his court appointment. During the next
ties were recorded, but no reinforcers were provided. In several months, Mr. B continued applying for jobs and
weeks 7–18, the reinforcers were instituted, first in Tues- eventually obtained a position. He located an apartment
day groups (weeks 7–12) and then in Thursday groups in which he still resides. He cleared up legal and financial
(weeks 13–18). The structure and content of the incen- documents related to disability, filed income taxes, and
tive and nonincentive groups were identical, with the ex- became active in Narcotics Anonymous. He also enrolled
ception that in the incentive groups, clients earned in the center’s mentor program, where he meets weekly
draws from a prize bowl for the number of consecutive with a peer to discuss drug use and HIV. He reestablished
weeks that they attended group. They earned additional relationships with his children, including attending fam-
draws for completing weekly activities. If objective verifi- ily therapy with one of his daughters.
cation (e.g., receipts) of completion of an activity was Working on his attitude remained a major area of fo-
brought to group (see reference 15 for description of ac- cus throughout Mr. B’s participation in the groups. He set
tivities and verifications), clients earned one additional specific activities, such as attending weekly individual
drawing. If they successfully completed and verified both sessions with a counselor, completing anger manage-
of their activities in a given week, they earned bonus ment worksheets and diaries, smiling and saying “hello”
draws that escalated with the number of weeks that they to people at the center, and refraining from arguments.
completed both activities. The probabilities of winning He also began volunteering at the center; he cooked,
prizes, and the types of prizes available, were similar to signed up for clean-up duty, and created posters and
those described in case 1. The only difference was that floats for community events. Since joining the groups,
prizes were solicited from donations whenever possible Mr. B has not once been reprimanded or asked to leave
as well as purchased by a research grant. the center.
In weeks 19–24, the magnitude of the reinforcement Beginning his second month in treatment, Mr. B iden-
was decreased, such that each client earned just one tified improving his health as another major goal area.
draw from the prize bowl for attendance on Thursdays He scheduled and attended medical appointments and
only. For each activity they completed, their name went was reinstated on a regimen of HIV medications (indi-
into a second urn. One person’s name was drawn from navir sulfate, lamivudine/zidovudine, and ritonavir) and
that second urn at the end of the session, and that indi- reported full compliance for the first time. For some of
vidual received 10 draws from the prize bowl described his activities, he also met with a nutritionist and a physi-

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CLINICAL CASE CONFERENCE

cian to initiate new eating and exercise regimens. Al- Case 3

though he reported a poor appetite, he agreed to eat a
full lunch at the center daily as one of his activities. He Initial Assessment
stated, “Once I got the virus, I didn’t care about nothing.
Nothing! Now, I’m trying to be healthy and to take care Mr. C was a 47-year-old, single Caucasian male veteran
of myself. My doctor is really happy with me. He can’t be- diagnosed with chronic paranoid schizophrenia, cocaine
lieve how I’ve changed.” dependence, polysubstance dependence, and antisocial
Throughout this demonstration project, Mr. B earned personality disorder. He received a veteran’s pension of
126 draws from the prize bowl for attendance and activ- $1,196/month and $750/month in Social Security Dis-
ity completion. These draws resulted in 60 small prizes, ability Insurance. Mr. C had a conservator for his per-
seven large prizes, and one jumbo prize. Even though no sonal and financial affairs. He had been unemployed
drawings had been available for the preceding 2 since his discharge from the service in 1975, and he in-
months, Mr. B continued participating in group and indi- termittently earned money for drugs as a “gypsy” cab
vidual sessions. Although urine sample testing was not driver, ferrying sellers and buyers to make their deals.
conducted at this clinic, Mr. B did not once appear at the Lack of housing was a chronic problem. For much of
clinic intoxicated since attending groups. He admitted to his adult life, Mr. C had lived on the streets or slept in the
regular use of alcohol and marijuana but reported no co- back of his cab. Efforts by the dual diagnosis team to
caine use in the past 4 months. place him in rest homes, shelters, and hotels were
Mr. B has become a strong proponent of the program, thwarted because of a reluctance of staff at these facili-
frequently encouraging other clients to attend. He ties to accept Mr. C. This reluctance was due to his anti-
stated, “This program is not just about talking about us- social and drug use behaviors and because he would
ing and not using. It’s different. It’s about changing your leave abruptly without payment. In response to his cha-
life. This program changed me really a lot. I used to have otic environment, Mr. C developed a pattern of frequent-
a really shitty attitude, defensive, hostile, angry. I’d come ing the psychiatric emergency room asking for food and
in drunk or high. Now, I did a 180-degree turn. I’m re- a bed. He would come in intoxicated and often would
sponsible now. The other addicts, they see how I’ve call ahead to notify staff that he would be coming in for
changed, and they don’t believe it. They knew me when food and shelter. When refused, he would threaten sui-
I used to fight when anybody just looked at me wrong. cide. For several months, this scenario was repeated up
They don’t want to be me, but some of them, they want to 15 times per month.
to be like me. I’ve become a beautiful person.” In the fall of 1999, Mr. C again appeared at the psychi-
atric emergency room. On this occasion, he was intoxi-
Review and Comments cated, carrying razor blades, complaining of auditory
The use of contingent reinforcement for attendance at hallucinations, and threatening to kill himself if not pro-
group seemed to be an ideal approach for engaging this vided shelter. Mr. C was admitted to the inpatient psychi-
atric unit for stabilization and safety. A plan was devel-
client in treatment for the first time. The subject admitted
oped to address his worsening problems and chronic
that his initial interest in attending the groups was simply
misuse of the psychiatric emergency room.
for materialistic gain. However, after attending several ses-
sions, the focus shifted from external reinforcement to a Developmental History
combination of external and internal motivations to en-
Mr. C had no substance abuse or psychiatric problems
gage in treatment, as evidenced by his attendance on non-
in his family of origin. He reported sexual abuse by his
incentive days and his continued participation and com- father until age 8 and stated that his mother had his fa-
pletion of goal-related activities even after all material ther arrested when she discovered the abuse. Mr. C
incentives were discontinued. The new behavior patterns never married and frequents prostitutes.
seemed to become self-reinforcing; he enjoyed the social Mr. C was in the army for 3 years in the 1970s. He was
reinforcement he received from other addicts, who com- stationed in Germany when he suffered a “psychotic
mented on his change in attitude. His improved relation- break,” during which he “ran around naked.” He was
ships with his children also seemed to encourage his less hospitalized first in Germany and then transferred to the
hostile attitude. The support he received from his physi- United States. After a course of hospitalizations, he was
released from the service with an honorable discharge
cian in conjunction with new eating and exercise regi-
and awarded 100% service-connected disability in 1975.
mens reinforced his healthier lifestyle as well.
Mr. C’s initial drug use began at the age of 16 with mar-
In part because of its unique setting (a drop-in clinic), ijuana and LSD. He later began to use cocaine and alco-
this project utilized a very individualized and nonjudg- hol. He used combinations of these drugs beginning in
mental approach toward substance abuse treatment. Cli- his late teenage years through his early 30s. In 1983, he
ents could decide upon specific problem areas on which was assigned a conservator for his financial affairs be-
they focused their efforts. Thus, drug abstinence was en- cause he was spending about $600 weekly on crack co-
couraged but not mandated as a goal area. Had this clinic caine. His longest period of sobriety occurred while in-
agreed to conduct urine testing, this subject may have carcerated or hospitalized on a psychiatric ward. Mr. C
had been enrolled in a series of drug rehabilitation, work
benefited further from contingent reinforcement for drug
therapy, and community rehabilitation programs, but he
abstinence. Although his self-reports of cocaine absti- had never completed any successfully. He also had un-
nence may have been suspect, he did not appear at the dergone 40–50 psychiatric hospitalizations secondary to
clinic intoxicated since he had become involved in the drug-induced psychiatric decompensation and poor
contingency management project. compliance with antipsychotics.

698 Am J Psychiatry 158:5, May 2001

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Mr. C had a long history of impulsive and violent be- clean urine sample. This was a landmark event, since it
havior, including threatening his clinicians and other pa- was the first drug-free urine specimen Mr. C had pro-
tients. He was jailed for 8 months a few years earlier for duced in years outside of a controlled environment. That
assaulting his clinician while an inpatient. At the time of Friday morning he also received his haloperidol de-
implementation of the contingency management pro- canoate injection. Mr. C met all four conditions of the
gram, he was transferred to a new clinician after threat- contingency management plan his first week. He was
ening to kill his previous one, and he was serving a 1- congratulated and encouraged to maintain sobriety and
year probation for assaulting an elderly patient during a remain housed at the motel.
recent hospitalization. For the first 8 weeks, Mr. C honored his appointments,
provided clean urine specimens, took his haloperidol de-
Behaviors to Target canoate injection, and did not visit the psychiatric emer-
We noted that Mr. C’s misuse of the psychiatric emer- gency room intoxicated or demanding food and shelter.
gency room gradually developed over time, resulting However, he began complaining of anxiety and re-
from the reinforcement he received for his inappropri- quested lorazepam. Because lorazepam was a drug he
ate behaviors. Each time he threatened suicide, he was had previously misused, his olanzapine dose was ad-
provided food and a place to stay. justed instead. Rather than receiving an oral dose of 15
mg at bedtime, he was switched to a regimen in which
Mr. C exhibited a variety of inappropriate behaviors
he received an oral dose of 5 mg every morning and an
that were not only detrimental to him but also to the
oral dose of 10 mg at bedtime. This dose adjustment al-
functioning of the psychiatric emergency room. The
leviated his anxiety symptoms, and Mr. C made no fur-
most crucial problem behaviors seemed to be cocaine
ther requests for lorazepam.
use, lack of appropriate housing and subsequent crisis-
related psychiatric emergency room visits, nonatten- At this time, the dual diagnosis team decided to add an
dance at therapy, and poor compliance with antipsy- additional reinforcer to Mr. C’s contingency management
chotic medications. Because no research grant was avail- plan: if he could follow the plan for a total of 3 months he
able to provide funds for reinforcers, an individually would receive an unspecified cash bonus. Mr. C suc-
tailored plan using no-cost reinforcers was created. ceeded in maintaining 12 weeks of continuous sobriety.
He was congratulated for this remarkable achievement
Contingency Management Plan and given a $100 bonus the following Monday. In addi-
tion, his conservator gave him $100 extra to purchase
A plan was developed to reinforce appropriate behav- Christmas gifts for his family. The team also informed him
iors along each of the aforementioned four domains by that if he could remain drug free for another 3 months,
using cash from Mr. C’s entitlements as the reinforcer. As he would get another bonus—double the amount given
part of this plan, the conservator paid Mr. C’s rent for the first bonus. Mr. C agreed to strive for this absti-
directly to a local motel and provided Mr. C with $30 per nence goal.
day for food and clothing. These monies were provided For 4 months from the initiation of the contingency
noncontingently. To receive the remainder of his management plan, Mr. C gave drug-free urine samples,
monies, Mr. C was required to 1) provide drug-free urine made scheduled visits to his therapist, complied with
specimens twice per week at the psychiatric emergency medications, and remained housed at the motel. With
room; 2) stay at the motel and not show up at the psychi- time, his overall grooming and hygiene improved, fol-
atric emergency room at any time other than to provide lowed by a marked improvement in mood and cogni-
the scheduled urine samples; 3) meet with his clinician tion. Mr. C demonstrated several instances of good judg-
on Friday mornings; and 4) receive his monthly haloperi- ment as he resisted temptations to use drugs. He opened
dol decanoate injection at the scheduled times on Friday a savings account with the money he was earning from
mornings. the contingency management plan. He was very cooper-
Clean urine toxicology screens were reinforced at the ative, looking forward to individual therapy, in which he
rate of $15 each, and Friday meetings with the clinician often discussed his family. He planned to reestablish con-
and not appearing in the psychiatric emergency room tact with them.
for room and board during the week resulted in $25. Until the institution of this plan, Mr. C’s mother had
Accepting the monthly haloperidol injection was rein- maintained little communication with him and reported
forced at $30. Thus, most weeks, Mr. C could earn up to difficulty relating to him because of his antisocial behav-
$55 and $85 for the week he was scheduled for the halo- ior. During his period of sobriety, they reestablished
peridol injection. On Fridays, the clinician called the con- contact, and Mr. C spent the holidays with his mother
servator and reported the conditions of the contingency and sister for the first time in many years. He gave them
management contract that Mr. C met. The amount he both gifts, a gesture he rarely had made in the past. He
earned was disbursed from his funds on Mondays. reported developing a good relationship with his family
and stated, “This is the first time I can give them any-
Clinical Course
thing good for Christmas.”
The contingency management intervention was insti- After 17 weeks of continuous sobriety, Mr. C relapsed
tuted on the day of Mr. C’s discharge from the inpatient to drug use. The precipitating events related to this re-
unit. Mr. C was eager to initiate the contingency manage- lapse are unknown. He was able to achieve an additional
ment plan upon his discharge. He stated, “I’m sick and 6 weeks of cocaine abstinence about 2 months later but
tired of fighting with [the conservator] about my money. then relapsed again. Although he is abusing cocaine, Mr.
I need it when I need it. If this is what I got to do to get C continues to honor his clinic appointments, take his
my money, I’ll do it.” In the first week, Mr. C honored his monthly haloperidol decanoate injection, and reside at
first appointment and under supervision produced a the motel. He maintains enthusiasm for the contingency

Am J Psychiatry 158:5, May 2001 699

CLINICAL CASE CONFERENCE

management plan, even though he is not earning all his with goal-related activities (case 2), and appropriate clinic
money. As yet, he has not appeared unexpectedly at the attendance (and nonattendance), cocaine abstinence,
psychiatric emergency room or engaged in violent be- and medication compliance (case 3). In each case, in-
havior toward staff. Efforts are continuing to reengage
creases in the target behaviors were noted during imple-
him in sober treatment again.
mentation of the contingency management plan com-
Review and Comments pared to the noncontingent conditions.
This contingency management plan had long-term effi- A common criticism of contingency management pro-
cacy for encouraging therapy attendance, enhancing cedures is that their effects may dissipate when the rein-
compliance with antipsychotics, and reducing crisis-re- forcer is removed. In two of these cases, continued benefi-
lated psychiatric emergency room visits. It is notable that cial effects were demonstrated even after discontinuation
the subject has not been hospitalized in over a year since of the contrived reinforcer. The subject in case 1 main-
the onset of this contingency management plan. tained gains in terms of drug abstinence as well as overall
quality of life throughout a 6-month follow-up period, and
This contingency management approach had partial ef-
the subject in case 2 attended groups that were not linked
ficacy in reducing drug use. Since the plan was initiated
to reinforcement both during and after the reinforcement
immediately after the subject left the inpatient unit, while
phases. The ultimate goal of contingency management in-
he was drug free, the reinforcers seemingly were sufficient
terventions is for the target behavior to eventually become
enough to maintain abstinence. Unfortunately, this con-
self-reinforcing. In the first case, abstinence may be rein-
tingency management plan was unsuccessful in main-
forced through take-home methadone privileges and an
taining long continuous periods of abstinence. Perhaps
improved quality of life. The change in attitude, family re-
larger magnitude reinforcers were necessary for changing
lationships, and health behaviors of the subject in case 2
drug use behaviors. While he received $210 per week non-
may support continued cocaine abstinence and pro-so-
contingently, clean urine samples only provided $30/
cial behaviors. Although the subject in the third case con-
week. While $25/week and $30/month may be sufficient
tinued abusing cocaine, stable housing arrangements may
to reinforce appropriate use of the psychiatric emergency
prevent further crisis-related psychiatric emergency room
room and medication compliance, reinstating cocaine
visits. It is important to note that contingent disbursement
abstinence following a relapse may require a reinforcer of
of disability payments can continue indefinitely. While
larger magnitude (16, 17). Nevertheless, the subject’s
these three cases do not provide evidence of the long-term
drug-related problems remain considerably lower than in
efficacy of contingency management, they do suggest
pre-contingency-management periods.
some potentially enduring effects and methods by which
some behaviors may be reinforced long-term.
Discussion
Because drug abuse is a chronic relapsing condition,
These cases illustrate the impact of contingency man- complete abstinence may be an unrealistic goal, espe-
agement procedures on clients participating in a random- cially in difficult dual-diagnoses cases. A retrospective
ized trial, a demonstration project, and an individually de- analysis of predictors of long-term abstinence in cocaine-
signed intervention. The cases were selected from three dependent patients receiving both contingency manage-
distinct settings, targeted different types of behaviors, and ment and noncontingency management treatments finds
employed reinforcers ranging from $0 to $300 in addi- that duration of continuous abstinence is the best indica-
tional programmatic costs. These cases should not be in- tor of long-term outcome (18). Some clients are able to
terpreted as evidence of the efficacy of contingency man- achieve long periods of abstinence through 12-step and
agement, since they are simply examples of clients who standard treatment approaches. These patients may not
responded favorably toward these procedures. Instead, benefit substantially from the addition of contingency
the focus of this discussion is related to the application of management. A significant proportion of substance abus-
contingency management procedures in clinical practice, ers, however, never come in for treatment, and among
using these cases as examples. those who do enter treatment, attrition rates are very high
These three cases share some similarities. The clients (19–21). A primary benefit of positive-incentive contin-
were all chronic substance abusers who were resistant to gency management approaches is that they increase the
attending or had difficulty succeeding in standard treat- percent of patients who respond favorably to treatment.
ment. They all had some degree of co-occurring psychiat- These cases are illustrations of individuals who did not en-
ric illnesses, ranging in severity from intermittent explo- gage in or significantly benefit from standard therapy.
sive disorder, bipolar disorder, and cocaine-induced When the contingency management plans were initiated,
psychotic episodes to paranoid schizophrenia. Their drug their progress dramatically improved.
use and psychiatric illnesses resulted in a variety of health It is important to note that in these three individuals,
and psychosocial difficulties including unemployment, le- improvements were not confined to the target behaviors
gal problems, and repeated hospitalizations. but rather seemed to extend to other areas of functioning
The three contingency management interventions rein- as well. Reductions in cocaine and opioid use for the first
forced different target behaviors: cocaine and opioid ab- subject were associated with increased compliance with
stinence (case 1), attendance at group and compliance psychiatric medications, reductions in psychiatric hospi-

700 Am J Psychiatry 158:5, May 2001

 CLINICAL CASE CONFERENCE

talizations, and improvements in quality of life. The sec- As more and more clinicians and researchers apply
ond subject’s initial goals of obtaining employment and contingency management procedures to treat substance
improving his attitude expanded over the course of treat- abusing patients, new developments and refinement in
ment to reestablishing contact with his children and im- the techniques may emerge. We may discover less expen-
proving his health, including complying with HIV medica- sive yet efficacious reinforcers, determine the best be-
tion. Likewise, cocaine abstinence resulted in overall haviors to target, and evaluate the time course and opti-
improvement of grooming, cognition, and family relation- mal duration of interventions. Case examples such as
ships. In randomly selected and larger samples, controlled these do not provide evidence of efficacy of the proce-
studies may evaluate the efficacy of contingency manage- dure, but they may demonstrate real-world application
ment procedures in engendering these and other benefi- of the techniques.
cial effects.
Received Oct. 5, 2000; revision received Dec. 20, 2000; accepted
These cases illustrate the use of two different types of re- Jan. 8, 2001. From the Department of Psychiatry, University of Con-
inforcers. In studies of contingency management interven- necticut Health Center; the Veterans Affairs Healthcare System, West
tions, a variety of other reinforcers have been utilized, rang- Haven, Conn.; and the Yale University School of Medicine, New Ha-
ven, Conn. Address reprint requests to Dr. Petry, Department of Psy-
ing from dose changes (22) and take-home privileges (23)
chiatry, University of Connecticut Health Center, 263 Farmington
in methadone programs to cash (24) and voucher (9) incen- Ave., Farmington, CT 06030-3944.
tives. The prize approach used in cases 1 and 2 was devel- Supported by NIH grants DA-12056, DA-13444, DA-05626, DA-
oped to decrease the cost of reinforcement relative to the 09241, DA-09250, DA-04060, AA-03510, DA-0454, and RR-06192.
The authors thank the staffs of the Community Substance Abuse
voucher system (11). The use of contingent disbursement
Center, The Living Center, and the West Haven VA Department of Psy-
of disability payments is a novel, no-cost reinforcement ap- chiatry for assisting in patient care.
proach (25–27). Reinforcement is provided in traditional
substance abuse treatment programs as well. Examples in-
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