You Pick the Reward

– Marcus Shumate, LCAS, LPC

A saying that has emerged in our young men’s program is “the patient picks the fun.” As I write that sentence it occurs to me that I should clarify what we mean by “fun”. We are all responsive to things we find “fun” and/or “meaningful”. These things “reward” our behavior and increase the chances we continue to do them. Our behavior becomes shaped by the things we do that bring us a sensation we find pleasurable. The things we find “rewarding” we will continue to do. This process can be hijacked and go in harmful directions. If you’re reading this entry then addiction likely springs to mind as the most obvious way this process gets hijacked in harmful ways. The following question likely seems too simple, but it’s an important one: how can we hijack these ideas and use them in a healthy direction?

It’s the question that is most closely connected to our saying “the patient picks the fun”. We have found that when we provide our patients with as many options for fun, meaning, and connection they tend to become more invested and engaged in their own recovery process. It makes sense. Why get sober if life will be miserable? All of this sounds simple enough, but, here is where it gets complicated; what is reward for the patients and how do we pick that? Simple, we don’t. If we try to pick what we think will be rewarding for our patients we will likely fail.

I have a very recent example of this in my mind. We recently had a group of patients in our young men’s program that we challenged to brainstorm as a group and develop a recreation event that we would help facilitate. I wrongly assumed and said to the group that they probably wouldn’t be interested in attending the gym and going bowling afterwards since they had gone bowling recently and attended the gym the day before. I was wrong and they quickly let me know. I had assumed that they were sore from their previous day at the gym and since they had recently gone bowling that they wouldn’t be interested in that. Their motivations for both of those activities were unknown to me because, despite our program’s spirit, I had assigned low rewarding value to both of those options while they had assigned much higher rewarding value to them. As a result, I made assumptions based on that belief and incorrectly guessed what they would find fun. In sticking with our program’s spirit of “the patient picks the fun”, I should have had the group drive that process while providing guidance. The group explained to me that they had previously talked to the coach at the gym and were interested in the workout that was planned for that day and that when they previously went bowling they had fun doing it sober and that outcome was anxiety-reducing. Most of the group had never bowled sober or spent time in a large group of peers laughing while sober and had experienced a lot of anxiety about the possibility that they could have fun in that way.

I should clarify that our job as the clinical team is to make sure that we provide a hearty menu of options for them to seek out, but our job is to make sure that the options on the menu are in line with the direction of recovery. What we have repeatedly heard from our patients during their exit interviews is that the fun they had during these recreation assignments were the most important of their treatment process. Our pride would love that it be amazingly elaborate and well-designed staff interventions that were the most important part of the treatment process, but, that doesn’t often seem to be the case. In the end it makes sense. A person isn’t likely to recover if they don’t have something more appealing to recover to. Finding creative ways to provide our patients the opportunity to be invested in their recovery process and building a meaningful life is ultimately going to yield better and more sustained outcomes than more conventional forms of treatment. Again, there is nothing new in this approach. Many education systems have adopted this approach and it’s full of principles from behavioral science.

Can you train a child to engage in a behavior by using the “reward” of the world’s finest and most expensive chocolate? It depends on how much that child values that chocolate. If the child doesn’t like chocolate you aren’t likely to get very far. If you take the ideas in this and apply it to treatment you can say the same thing regarding any treatment modality. Is wilderness treatment the best treatment for young adults? It depends on how much of a fit that is for the patient. The same goes for us. If we aren’t the right system for a patient then it will be more difficult to provide a menu of rewarding options that can properly draw a patient towards recovery. As a field we have to improve in this area. We are dealing with a complicated addiction problem that is driving young people into treatment earlier. We have to be flexible and thoughtful in our approach in order to provide more rewards for recovery. We can’t escape the truth that the patient is “right” when they pick what’s rewarding; all we can do is be smarter about providing a menu of rewarding options that motivate a sustained recovery.