Transcript Resilience: - Scotland's Futures Forum

Designing Services for Recovery:
Toward Sustained Recovery
Management
William L. White, MA
Chestnut Health Systems
Bloomington, IL USA
Email: [email protected]
Presentation Goals
1. Describe the contextual forces that are
triggering the call for a fundamental
redesign of addiction treatment
2. Outline how service philosophies and
practices are changing within “RecoveryOriented Systems of Care” (ROSC)
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
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 “Recoveryoriented Systems of Care”
Recovery Mutual Aid Societies
• Growth in size and geographical dispersion
• Philosophical diversification (religious, spiritual,
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secular; moderation-based)
Group specialization by drug choice, age,
gender, sexual orientation, occupation and cooccurring 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
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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
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
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
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
1. Acute care model that focuses on brief
biopsychosocial stabilization without
sustained recovery support.
2. Chronic care model that began with a
vision of comprehensive rehabilitation for
chronic heroin dependence
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 evershorter) 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
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”
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….
• Weak attraction (less than 10% in any year;
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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, But…
• Inadequate quality (limited in scope of services
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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 readmission rates (25-35% within one year)
Existing Treatment Works, But…
• In the U.S, 64% of clients admitted to addiction
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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)
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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 orientation, e.g., mission,
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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 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 Elements
• Assertive approaches to continuing care (e.g.,
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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
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 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.