Teen substance use can be difficult to treat, as many see experimenting with drugs or alcohol as a normal part of growing up. Often, teens enter treatment reluctantly, only because their parents insisted.
The current best practices for treating substance use and addiction include family-based therapy and a combination of cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET). Another tool, called contingency management (CM), offers a way to engage teens and boost the success of their treatment. Evidence shows CM is effective at keeping adolescents in treatment, increasing their attendance and promoting abstinence when used as part of a comprehensive program. Yet despite its success, CM is underutilized. Barriers, from ethical concerns to funding limitations, have kept some providers from adopting it.
In this Q&A, discover how behavioral health specialists at Children’s Medical Center Dallas, part of Children’s Health℠, are utilizing contingency management to make a difference.
What is contingency management (CM)?
CM is a principle of positive reinforcement, offering rewards when teens demonstrate desired behaviors, such as negative drug tests and attending weekly counseling sessions. For each consecutive success, the value of the reward increases, which helps motivate patients to keep a good thing going.
“Stringing together several weeks in a row of clean drug screens has a real impact on long-term change,” says David Louis Atkinson, M.D., Medical Director of the Teen Recovery Program at Children’s Health and Associate Professor at UT Southwestern. “When patients get time away from drugs, they start to believe they can reach their goals and drugs become much less appealing. Teens who experience a few months of drug-free life can do a lot of maturing. They start to see ‘This is how substance use hurt me,’ and ‘Here’s how I can make my life better.’”
How do rewards support recovery?
The evidence behind CM is strong across different types of substances and it’s most effective when combined with other therapies – like cognitive behavioral therapy and motivational enhancement therapy. In the seven years since Children’s Health incorporated CM into their Teen Recovery Program, Dr. Atkinson has seen CM support teens in several ways.
- It injects positivity into a process that can feel confrontational. Adolescents tend to get desensitized to negative consequences. CM taps their desire to get something they want rather than only avoid things they don’t want.
- It motivates patients during early abstinence. Even after withdrawal symptoms pass, patients may struggle for a while with sleeping, eating and thinking clearly. CM provides a reason to try when abstinence doesn’t feel good.
- It trains the brain to accept delayed rewards. Substance use can shorten a person’s sense of the future, which makes it hard for them to value benefits that aren’t immediate. Having to wait for a weekly reward helps shift their mindset.
- It encourages adolescents to engage in therapy. Patients may rightly sense they have difficult work ahead in sessions with therapists who will challenge their thoughts. CM helps offset the stress of this process so it’s easier to allow new thoughts in.
Which barriers limit the use of contingency management?
Though most healthcare providers are convinced by the research on CM, some people in the larger culture raise ethical concerns about using rewards to convince patients to stay clean, which may be one reason CM isn’t used more widely.
“Broader integration of CM into teen recovery programs would help us help more patients,” says Dr. Atkinson. “While it’s important to not dangle the promise of a reward to get teens to start treatment if they aren’t otherwise ready, the benefits of CM are clear once treatment begins.”
The “payments” are only a bridge, he notes. Over time, the focus shifts from the incentives to life’s natural rewards. More importantly, research shows that people don’t relapse as soon as the rewards stop, as long as they’re in a comprehensive program that provides therapy.
The cost of the incentives is another barrier to wider use of CM. Insurance generally won’t cover the rewards, so providers often turn to grants or philanthropy for funding. This solution raises issues of its own. For example, when a grant ends, providers need a new funding source. And some funders limit the amount of money a program can spend per patient per year on CM – even though evidence supports using higher-value rewards. With policy changes that would allow insurance coverage and other forms of sustainable funding, more programs would be able to offer CM if they want to.
Why Children’s Health: Comprehensive substance use care
Children’s Health is the only treatment center for teens in North Texas using CM as part of a comprehensive program.
After a detailed evaluation, teens in the program do individual, family and group therapy. They also take weekly rapid drug tests and are rewarded for clean tests with gift cards from a retailer or restaurant. Children’s Medical Center Foundation funds the gift cards.
Parents are involved in treatment too and families get long-term support. To give teens the best chance for success, the program provides care for both substance use and mental health conditions, such as depression and anxiety.
