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

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designing services for recovery toward sustained recovery management

Designing Services for Recovery:Toward Sustained Recovery Management

William L. White, MA

Chestnut Health Systems

Bloomington, IL USA

Email: bwhite@chestnut.org

presentation goals
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)
new monographs
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.

recovery revolution defined
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”

recovery mutual aid societies
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.

recovery community institution building
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.

recovery community cultural development
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

new recovery advocacy movement
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.

toward a recovery paradigm
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

two prevailing models of addiction treatment
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
the acute care model
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

the chronic care model
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)

treatment works
“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

existing treatment works but
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)
existing treatment works but15
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)
existing treatment works but16
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

toward a model of sustained recovery management rm
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

recovery management emerging elements
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
recovery management emerging elements19
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
recovery management emerging elements20
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
closing thoughts
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.

closing thoughts22
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.