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Making recovery more rewarding: difficult with possible unintended consequences, but successful examples are out there.

I want to thank the people who wrote these four commentaries for their thought-provoking reactions and suggestions. Best [1] highlighted theoretical and interventional work with criminal justice populations that has stressed the importance of meaningful activities, relationships and the community to sustained desistance. The findings from these studies appear to be quite consistent with the arguments I am making, and I greatly appreciate Best’s references to this body of work. Lancaster [2] cautioned against conveying that, to be in recovery, one must not only be abstinent but also improve in other major domains of functioning and become a productive citizen. I agree completely, which led me to think that I must not have been entirely clear in my arguments. My point was not that those with substance use disorders ought to be striving to both stop using alcohol and drugs and become good citizens according to societal norms. Rather, I proposed that providingmore opportunities to engage in enjoyable andmeaningful activities might convince some individuals that there were compelling reasons to continue to abstain from alcohol and drugs [3]. Wincup [4] highlighted potential problems with incentives, including that they can be coercive. She also questioned how incentive-focused treatment would deal with clients who do not get better. I recommend providing help in finding and engaging in rewarding activities for a relatively long period (for instance, a year), regardless of whether or not the client has stopped using, in the hope that participation in such activities will eventually help to increase rates of sustained recovery. Wincup’s second concern, that incentives can erode intrinsic motivation, applies particularly to the use of cash or voucher-based incentives linked to drug-free urine samples or attendance at treatment sessions. However, I am not proposing greater use of these kinds of incentives. Instead, I am suggesting that individuals with substance use disorders be given more help to identify and engage in activities that will be pleasurable and rewarding. At least in some cases, these could be activities that are essentially cost-free or at least not overly expensive, and could be sustained by individuals in recovery once they come to value them. However, the potential for unintended consequences should be acknowledged when providing incentives or rewards, whether or not contingent upon performance. Kelly [5] makes three excellent suggestions that would advance work on how to make recovery more attractive: asking people in recovery how they got better (which Lancaster also recommended), promoting recovery support services in the community that can provide an entree to rewarding activities and recognizing that there will be important individual differences in the kinds of experiences that will be most rewarding. The insights of those who have been successful in recovery might not always be relevant to those who continue to struggle. However, I agree that we can still learn much from these individuals, and I entirely support greater use of and research on recovery support services. Finally, as Kelly states so clearly, interventions consistent with what I have proposed, whether provided by the treatment systems or other agencies, will have to be highly individualized.