Cognitive management is an effective type of addiction treatment that incorporates rewards or incentives for maintaining sobriety or other positive behaviors, while also withholding rewards or providing consequences for undesirable behaviors. It has been shown to be effective for several issues, including impulsive behaviors, defiance, and substance abuse.
Through slight modifications, CM can fit a range of client needs, depending on each individual person. It can be used as a stand-alone treatment or in combination with other treatment styles, including CBT, medication management, and motivational interviewing.
The basic ideas of CM are that rewarded behaviors are more likely to continue and increase in frequency, punished behaviors are more likely to be reduced in frequency until they are eliminated, and behaviors that are ignored, given no reinforcement or no punishment will be reduced until eliminated.
CM works under the assumption that substance use is influenced by a range of factors, such as social, environmental, and biological factors. On a number of levels, substance use creates a rewarding experience for users. The high they experience or the excitement surrounding the use outweighs all else. This is why people who suffer from addiction continue to use substances despite the harm and negative consequences that they bring.
Someone at the beginning of the recovery process may face strained relationships, a poor financial situation, and ailing mental and physical health as a result of substance abuse. This new situation is not rewarding and will feel like punishment for sobriety.
People entering a CM program will have the opportunity to be rewarded for desirable behaviors and if they attend treatment and avoid unwanted behaviors, the chances of reward grow. Ideally, the reinforcement they get from the CM program will outweigh the perceived rewards of substance abuse. CM has been shown to be effective in treating alcoholism, opioid addiction, nicotine addiction, and more.
Although punishments can also reduce unwanted behavior, CM programs generally give them out sparingly. The reason is that punishments tend to damage the relationship between the person giving them and the receiver, which is undesirable in a therapeutic setting. Punishment is also related to a lack of engagement and consistency in treatment and recovery, and the fear of punishment nurtures a secrecy that can adversely impact recovery.
A successful CM program needs to focus on 7 principles to guide treatment:
- Target behavior
The first thing to do is identify the target behavior. This can be a positive behavior to be increased, or a negative behavior to be reduced. Negative behaviors will be associated with substance use and positive behaviors will be healthy substitutions.
- Choice of target population
Some people in recovery won’t need or may not want to participate because they already have enough intrinsic motivation to progress in treatment. CM will be more useful for new clients or people who have had poor rates of success in the past.
- Choice of reinforcer
The reinforcer is a central aspect of a CM program. What seems like a good reward for one person may have no value to someone else, so people in recovery need to be rewarded with something of interest to them, otherwise the goal will not be accomplished.
- Incentive magnitude
CM programs need to find a balance between what is practical and what is rewarding, and some people may need more than others in order to remain engaged. Some aspects to consider are past use, past success with recovery, strength of social supports, and past response to rewards.
- Frequency of rewards
Some programs will reward positive behavior each time it occurs, at a specified rate, while others will offer rewards at a variable rate in an attempt to receive the most benefit. The ideal rate is dependent on each individual’s needs.
- Timing of incentive
Timing is just as important as frequency and the best-case scenario is for the reward to be given immediately after someone has shown positive behavior. This helps build a strong link between wanted behavior and reward.
- Duration of intervention
The goal is to maintain the desire for sobriety even after the rewards are removed, and this will take longer for some people than it will for others. The decision to end the reinforcement will coincide with relapse prevention strategies to ensure a minimal risk of relapse.