Designing Services for Recovery: Toward Sustained Recovery Management

1. Designing Services for Recovery:Toward Sustained Recovery Management William L. White, MA Chestnut Health Systems Bloomington, IL USA Email: bwhite@chestnut.org

2. 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)

3. 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.

4. 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”

5. 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.

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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 client’s life rather than what is added (e.g., global personal/family health, productivity, life meaning/purpose, citizenship and service)

13. “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

14. 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)

15. 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)

16. 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

17. 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

18. Recovery Management:Emerging 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

19. Recovery Management:Emerging 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

20. Recovery Management:Emerging 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/recovery careers rather than immediate effects of single intervention

21. 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 treatment’s probationary status as a cultural institution.

22. 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.