Part 3. The reward chart

In medical CBT there are 3 levels of formality:

1. Goalification only (see December 2010 article¹)

2. Goalification and scalification (see January 2011 article²)

3. Goalification, scalification, and reward charting (this month’s topic)

Although many factors determine which level of formality is most sensible for a given patient, in the real world time is often the overriding issue. How long do you have with Mrs Jones today?

• 1 to 2 minutes ⇨ goalify only

• 4 to 5 minutes ⇨ goalify and scalify

• 10 to 15 minutes today, and likely the same several times again ⇨ goalify, scalify, and reward chart

A basic reward chart looks like this:

EFFORTS AND REWARDS	DATE 1	DATE 2	DATE 3	DATE 4
Efforts Fixitol 20 mg daily Exercise Social efforts Sleep habits
Rewards Happiness (1–10)

The term reward chart implies that patients are to a fair extent responsible for creating their own rewards (eg, moods). A precise a priori determination of the extent to which this is true for a given patient is impossible—it’s the old nature-versus-nurture debate—but fortunately most patients have more control than they believe.

In the medical CBT paradigm, adhering to a prescribed medication regimen is but one effort a patient can choose to commit to. Other efforts might include more regular exercise, increased socialization, and improved sleep habits. This is not to discount the role of medication—we know from research, practice, and sometimes personal experience that medication can be very helpful—but we must also emphasize other interventions.

Tips

• First, explain the effort-reward paradigm. Explanations are particularly needed for biological reductionist patients (ie, those who fatalistically believe that all is predetermined by neurochemistry). Encourage these patients to “experiment” with adjunctive interventions “in the meantime” (ie, until their medication kicks in).

• Next, complete the rewards section. Rewards are the antonyms of the control presenting complaints.¹ Common examples are happiness for depression; sense of belonging for loneliness; and calmness for anxiety. All rewards should be scalified (eg, happiness on a 1 to 10 scale).² Caution: patients with more than 2 or 3 goals will likely lose focus.

• Next, fill in the efforts section. Stick with tried-and-true efforts like medication adherence, physical exercise, social or nutrition efforts, and improved sleep regularity. Consider splitting “effort cells” diagonally. Enter the negotiated effort in the top left, and enter the patient follow-through in the bottom right. In the example below, the agreed-upon exercise effort was twice per week, but on follow-up the patient had exceeded expectations:

  Exercise	2/7
  	3/7

• Openly share the reward chart with the patient. In the ideal world, the patient becomes the chart’s steward, maintaining his or her own copy at home.

• Efficient follow-up begins with the reward scales.

• Take ample time to highlight the links between efforts and rewards. To us the links might be obvious, but to our patients with learned helplessness they are not.

• If good efforts were poorly rewarded, put on your coach’s jersey. Talk about “mood lag”: some efforts (eg, taking antidepressants) might not deliver results for many weeks. Insist on another round or two of experimentation with current efforts. Perhaps tweak some items. But beware: if a patient is chronic (eg, dysthymic), resist taking over as mood steward.

• If things are going well, curb your enthusiasm for adding more items (efforts or rewards). Go slowly and steadily.

Dr: Please tell me, Mrs Jones, what rewards have you gained on our chart here? [demonstrating chart] Last week you were a “3” on the happiness scale. Where are you today? [then review efforts] Last time we’d agreed to several efforts for those rewards. For our first effort—exercise—your target was twice a week. How was your follow-through?

You might have a sizeable healing aura. Sadly, patients seeing you 10 minutes a week can only experience that aura 10/(60 × 24 ×7) = 0.1% of the time. The reward chart reinforces for patients the fact that they must invest that other 99.9% of their lives wisely.