Contingency Management Therapy (CM) for Veterans with Addiction

Veterans represent a unique group who have faced distinct challenges during and after their service. Experiences such as combat exposure, physical injuries, stress of deployment, and the transition back to civilian life can increase vulnerability to substance use disorders (SUDs). 

Furthermore, co-occurring conditions like post-traumatic stress disorder (PTSD), depression, and anxiety are common, creating a complex picture where substance use may develop. Recognizing these factors is crucial when considering effective treatment approaches. Many therapeutic interventions exist that can help Veterans struggling with addiction; one of these is contingency management (CM). 

Continue reading to learn more about CM, how it works, and how CM benefits and works for Veterans. The page will also discuss the efficacy of CM and how to find suitable addiction treatment if you are a Veteran looking for help.

What Is Contingency Management (CM) Therapy?

Contingency management in substance use disorder treatment is a therapy strategy that uses positive reinforcement to encourage abstinence or adherence to treatment.¹Rewards are given when a specific goal is achieved.¹

CM holds the person accountable for meeting specific recovery goals.²It is solely their behavior that determines if they are rewarded.

How Does Contingency Management Work?

Long-term substance misuse causes changes in the brain’s reward circuitry such that it expects the immediate gratification that substances cause.²CM is thought to disturb this circuitry and orient the brain’s reward pathway to rewards other than drugs or alcohol.²Furthermore, CM helps to increase abstinence, which, in turn, starts to reverse the deficits to the reward and self-regulation pathways caused by drugs.²

Behaviors to be rewarded can be those such as abstinence from a particular substance (e.g., stimulants like methamphetamine or cocaine, alcohol, cannabis), reduction in use, attending treatment sessions, medication adherence, or reaching an anniversary of a date on which use stopped.³ 

The target behavior must be objectively measurable. For example, a negative drug screen provides verifiable evidence that the Veteran has met the abstinence goal. When a Veteran meets an agreed-upon goal, they receive a reward.

Rewards tend to be modest, but something of meaningful value. The two major forms of reward delivery are vouchers and prizes.⁴ Vouchers have a monetary value and can be exchanged for goods and services that support a healthy lifestyle (e.g., such as a gift certificate to their favorite restaurant or favorite activity like movie tickets or miniature golf).^3,5As long as a person continues to demonstrate the target behavior, the voucher value increases over time with, for example, consecutive negative tests, further incentivizing sustained abstinence.⁵

Prize draws (commonly referred to as the “Fishbowl Method”) involve drawing slips of paper from a bowl when the Veteran has a negative test or other verification of a target behavior. Most slips offer small notes of encouragement (“Good job!”), while some offer small prizes, and a few offer larger rewards. This element of chance can be highly engaging and motivating.

Who Can Benefit from Contingency Management Therapy?

CM is effective across various populations, with several factors making it a particularly valuable tool for Veterans navigating SUD recovery.

The first reported use of CM was in the late 1960s for those with alcohol use disorder (AUD).⁶ It was refined in the 1970s and 1980s for those with opioid use disorder (OUD) receiving methadone treatment.⁶However, CM can be used for the treatment of other addictions, including stimulant, cannabis, and tobacco use disorders.⁷

Contingency management is also effective for medication adherence among those with:⁸

The Veteran population particularly benefits from contingency management, as Veterans may be dealing not only with substance use disorders, but also with other concerns from their experiences while in service, such as medical conditions, PTSD, and other mental health conditions.

Why Is Contingency Management Particularly Effective for Veterans with Addiction?

The Department of Veterans Affairs (DVA) has included CM as a treatment option for Veterans since 2011, and now, more than 100 VA medical centers offer CM.² In addition to supporting abstinence from substances, CM has also helped Veterans with smoking cessation, adherence to AUD and OUD treatment medication regimens, and treatment/medication adherence for common co-occurring conditions including PTSD, depression, TBI, and chronic pain.^7,9

Incentives for attending therapy sessions can be especially helpful for Veterans. Because they are trained to be tough and not show vulnerability, opening up in therapy about their experiences can be all the more challenging and halt therapy progress.¹⁰ However, the incentives and rewards for positive actions provided by CM treatment helps to empower Veterans, reducing stigma often associated with mental health conditions and encourage them to attend sessions, gradually becoming more accustomed to the therapy setting. 

How Effective Is Contingency Management?

CM has been used with considerable effectiveness in treating individuals with a variety of SUDs (including stimulants, opioids, marijuana, alcohol, benzodiazepines, and tobacco cigarettes).¹¹

CM is very useful for treatment planning because it sets concrete goals and emphasizes positive behavioral changes. For example, research indicates CM improves treatment engagement—retaining nearly 50% of participants versus about 35% of those in standard care programs.¹¹

CM helps people maintain lengthier periods of abstinence during treatment, which is associated with a greater likelihood of long-term abstinence following treatment.²

However, CM is most effective when it is part of an overall evidence-based treatment approach.

Combining Contingency Management with Other Therapies

CM is most effective as part of a comprehensive, compassionate, and Veteran-centered strategy for treating addiction, which helps a person not only stay sober, but addresses the problematic underlying thoughts and behaviors that also contribute to substance use.

CM may be used with pharmacotherapy (medications for addiction treatment) as well as other types of behavioral therapy commonly used in inpatient and outpatient addiction treatment, including:

• Cognitive Behavioral Therapy (CBT). CBT helps the person recognize how problematic thoughts—often rooted in early life experiences—affect their emotions and behaviors. By working to change these negative core beliefs to more helpful ones, the person can experience more positive emotions and utilize healthier behaviors.¹²
• Motivational Enhancement Therapy (MET). Individuals with substance use disorder often struggle with internal conflicts, or ambivalence, about their use.¹³They are aware of the negative effects that substance use has on their life but may be pulled to use for pleasure or as a way to cope with difficult experiences. MET helps the person to continually weigh the costs and benefits of use to gradually move them closer to making healthy changes.¹³
• Dialectical Behavior Therapy (DBT). DBT is a structured therapy that combines skills training with psychotherapy. It consists of modules that are divided into different types of skills that can help to reduce substance use and increase positive ways of dealing with distress.¹⁴
• Eye Movement Desensitization and Reprocessing (EMDR). Almost 45% of those with a SUD also have PTSD.¹⁵ Some may use substances to cope with, or numb themselves from, PTSD symptoms. Thus, EMDR, used to treat trauma, can help reduce PTSD symptoms and, in turn, reduce substance use.¹⁵

Finding Addiction Treatment that Works for You

American Addiction Centers (AAC) appreciates and thanks Veterans for their service and how much they and their families have sacrificed in service to their country. We are proud to offer treatment centers that meets multiple needs of Veterans, including medical, psychological, and case management services; CM may be one part of an overall treatment strategy.

Speaking with a Veteran Liaison on our Veteran team can help you identify the type of treatment that works best for you. Those who work in our specialized Salute to Recovery program for Veterans are either Veterans themselves, spouses of Veterans, or have worked closely with Veterans for years. Therefore, we can also help you navigate the VA benefits system and answer any admissions, treatment or insurance questions you may have.

It is never too late to seek treatment, and recovery is possible. Call us today at to speak with an admissions navigator. We are here 24/7 and happy to help.