Much I won't attempt to argue with nor want to in what you say Rick but to stick to the narrow issue
of research on formal contingency management programmes as opposed to the 'contingencies' built in
to one's life. And lay aside also the ethical issues - I come from the original welfare state so I
just feel that if people and their children need housing food clothing etc they should have it,
regardless, but never mind that for the moment.
OK, the studies. I haven't got round to analysing this literature but I have read every study I have
been able to get hold of as I do other evaluation studies. My tentative conclusions are:
1.If you give poor people food or clothing or relief from boredom or whatever not to take drugs,
while you do that some are able to play the game, but when you stop they typically go back to
square one. The main reason why it looks good is that most of the research ONLY measures what
happens during the (typically) 12 weeks the contingencies are in place.See Prendergast M., Podus D.,
Finney J., et al. "Contingency management for treatment of substance use disorders: a
meta-analysis." Addiction: 2006, 101, p. 1546-1560.
2.Research repeatedly shows that the patients most in need of controlling their drug use never get
to the point of experiencing the incentives because they can't or don't want to control their drug
use in the ways demanded by the incentives. For them I fear this is just another failure and lost
opportunity to add to the demoralisation. What you get then is increasing inequality in rewards and
treatment outcomes; the already relatively good get better, the not so good lose out. This can be
overcome by well designed incremental incentives but often is not. See for example Stitzer M.L. et
al. Effectiveness of Abstinence-Based Incentives: Interaction With Intake Stimulant Test Results.
Journal of Consulting and Clinical Psychology: 2007 Vol. 75, No. 5, 805-811.
3. The impacts are usually limited to exactly what the contingencies demand. Patients if they can do
what's required but only what's required for as long as it is required. This is I guess because the
contingencies do not motivate the patient to address the roots of their problems, only to get the
prizes. Some studies find that compliance with contingencies is not associated with increased
motivation to sustain those changes. One actually found a decrease - Carroll K.M. et al.
"Contingency management to enhance naltrexone treatment of opioid dependence: a randomized clinical
trial of reinforcement magnitude." Experimental and Clinical Psychopharmacology: 2002, 10(1), p.
54-63.
4. All these generalities have exceptions. One PERHAPS is when CM is used to create a space for
healthy change and to encourage activities which promote such change and actually enhances rather
than mechanises therapeutic relationships (eg, Kellogg SH, Burns M, Coleman P, Stitzer M, Wale JB,
Jeanne Kreek M D M. "Something of value: The introduction of contingency management interventions
into the New York City Health and Hospital Addiction Treatment Service." J Subst Abuse Treat. 2005
Jan;28(1):57-65.)
For an enthusiast's account which admirably also covers these and other weaknesses and limitations
see: Carroll K.M. et al. A Perfect Platform: Combining Contingency Management with Medications for
Drug Abuse. American Journal of Drug and Alcohol Abuse: 2007 33, 343-365.
But of course our UK National Institute for Health and Clinical Excellence (NICE www.nice.org.uk)
has swallowed the research and regurgitated the half digested findings in its guidelines on
psychosocial treatment so who am I to gainsay these experts?
Regards
Mike
______________________________________________________________
Mike Ashton
DRUG & ALCOHOL FINDINGS
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