Designing Services for Recovery: Toward Sustained Recovery Management

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Designing Services for RecoveryToward Sustained
Recovery Management

• William L. White, MA
• Chestnut Health Systems
• Bloomington, IL USA
• Email bwhite_at_chestnut.org

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Presentation Goals

• Describe the contextual forces that are
  triggering the call for a fundamental redesign of
  addiction treatment
• Outline how service philosophies and practices
  are changing within Recovery-Oriented Systems of
  Care (ROSC)

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New Monographs

• White, W. (2008). Recovery management and
  recovery-oriented systems of care Scientific
  rationale and promising practices. See
  www.ireta.org
• White, W. (2009). Peer-based addiction recovery
  support History, theory, practice, and
  scientific evaluation. See www.glattc.org.

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Recovery Revolution Defined

• 1. Cultural/political awakening of communities of
  recovery
• 2. Emergence of recovery as an organizing
  paradigm for behavioral healthcare
• 3. Call for fundamental changes in the design of
  addiction treatment Toward Recovery
  Management and Recovery-oriented Systems of
  Care

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Recovery Mutual Aid Societies

• Growth in size and geographical dispersion
• Philosophical diversification (religious,
  spiritual, secular moderation-based)
• Group specialization by drug choice, age, gender,
  sexual orientation, occupation and co-occurring
  problems
• Growing varieties of recovery experience
• Sources White Kurtz, 2006, International
  Journal of Self Help and Self Care White, 2004,
  Addiction Humphreys, 2004, Circles of Recovery.

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Recovery Community Institution Building

• Recovery Community Organizations
• Recovery Homes and Colonies
• Recovery Schools
• Recovery Industries
• Recovery Ministries/Churches
• Recovery Community Centers, Recovery Social
  Clubs, Recovery Cafes
• Source White, 2008, Counselor.

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Recovery Community Cultural Development

• Cultural Consciousness Related to
• History
• Language
• Values
• Rituals of Celebration
• Literature, Music, Cinema, Art
• Source White, 1996, Culture of Addiction,
  Culture of Recovery

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New Recovery Advocacy Movement

• Political awakening of people in recovery
• Recovery Summits
• New and Renewed Recovery Advocacy Organizations
• Kinetic Ideas
• Advocacy and Anti-stigma Campaigns
• Recovery Month and Recovery Celebration Events
  (40,000 US participants in Sept., 2008)
• Source White, 2007, Addiction.

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Toward a Recovery Paradigm

• From Pathology (knowledge drawn from studies of
  addiction) and Intervention Paradigms (knowledge
  drawn from studies of treatment) to a Recovery
  Paradigm (knowledge drawn from collective
  experience study of long-term recovery)
• Call for Recovery-Oriented Systems of Care
• Source White, 2005, Alcoholism Treatment
  Quarterly Clark, 2007 Kirk, 2007 Evans, 2007

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Two Prevailing Models of Addiction Treatment

• Acute care model that focuses on brief
  biopsychosocial stabilization without sustained
  recovery support.
• Chronic care model that began with a vision of
  comprehensive rehabilitation for chronic heroin
  dependence

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The Acute Care Model

• An encapsulated set of specialized service
  activities (assess, admit, treat, discharge,
  terminate the service relationship).
• A professional expert drives the process.
• Services transpire over a short (and
  ever-shorter) period of time.
• Individual/family/community are given impression
  at discharge (graduation) that recovery is now
  self-sustainable without ongoing professional
  assistance
• Source White McLellan, 2008, Counselor

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The Chronic Care Model

• Vision medication-assisted metabolic
  stabilization for chronic opioid dependence as a
  foundation for long-term biopsychosocial recovery
  
• Model Deterioration dosing with inadequate
  clinical peer recovery support for psychosocial
  rehabilitation and community re-integration
• Focus what is subtracted/reduced (drug-related
  problems, crime, disease risk/transmission) from
  clients life rather than what is added (e.g.,
  global personal/family health, productivity, life
  meaning/purpose, citizenship and service)

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Treatment Works

• Efficacy and effectiveness established via
  enhanced outcomes compared to no treatment or
  non-specialized treatment
• Lives of many individuals and families
  transformed through the medium of addiction
  treatment
• Effectiveness influenced by problem severity and
  complexity and recovery capital
• Source Review in White, 2008 Monograph

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Existing Treatment Works, But.

• Weak attraction (less than 10 in any year 25
  in lifetime)
• Delayed engagement (late stage primarily
  through external coercion)
• Compromised access (waiting lists other
  obstacles)
• High attrition following Admission (more than
  50)
• Inadequate dose/duration (less than dose linked
  to best recovery outcomes)

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Existing Treatment Works, But

• Inadequate quality (limited in scope of services
  and by methods lacking scientific support)
• Passive rather than assertive linkage to
  communities of recovery high attrition
• Inadequate post-treatment continuing care
  (received by only 10-20 of clients)
• High rates (50) of post-treatment relapse (most
  within 90 days of discharge) high re-admission
  rates (25-35 within one year)

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Existing Treatment Works, But

• In the U.S, 64 of clients admitted to addiction
  treatment have one or more prior treatment
  episodes 19 have 5 or more prior episodes
• We are placing people in treatment whose design
  is incapable of generating sustainable recovery
  for many clients then blaming the clients for
  that failure.
• Sources White, 2008 Monograph

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Toward a Model of Sustained Recovery Management
(RM)

• Pre-recovery identification and engagement
• Recovery initiation and stabilization
• Sustained support for recovery maintenance
• Support for enhanced quality of personal/family
  life in long-term recovery
• --Emphasis on peer-based recovery support
  services and indigenous community support
• Source White, 2009, Journal of Substance Abuse
  Treatment

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Recovery ManagementEmerging Elements

• Recovery orientation, e.g., mission,
  representation, service philosophy
• Early engagement, e.g., assertive community
  outreach
• Increased access retention, e.g., streamlined
  intake, in-Tx recovery coaching and support
  services
• Assessments that are global, strength-based
  continual

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Recovery ManagementEmerging Elements

• Rapid transition from treatment planning to
  recovery planning / choice philosophy
• Expanded service team, e.g., inclusion of primary
  physicians, indigenous healers, recovery
  volunteers
• Assertive linkage to communities of recovery

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Recovery ManagementEmerging Elements

• Assertive approaches to continuing care (e.g.,
  recovery checkups) for up to 5 years
• Shift in helping role/relationship from expert to
  recovery consultant/partnership
• Focus on building personal, family community
  recovery capital, e.g. community development
  strategies
• Evaluation based on effects of multiple
  interventions on long-term addiction/treatment/rec
  overy careers rather than immediate effects of
  single intervention

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Closing Thoughts

• 1. ROSC and RM represent not a refinement of
  modern addiction treatment, but a fundamental
  redesign of such treatment.
• 2. Overselling what existing treatment models can
  achieve to policy makers and the public risks a
  backlash and the revocation of addiction
  treatments probationary status as a cultural
  institution.

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Closing Thoughts

• 3. It will take years to transform addiction
  treatment into a model of sustained recovery
  support.
• 4. That process will require replicating what is
  already underway in many locations aligning
  concepts, contexts (infrastructure, policies and
  system-wide relationships) and service practices
  to support long-term recovery for individuals and
  families.