Designing Services for Designing Services for Recovery:Recovery:

Toward Sustained Recovery Toward Sustained Recovery ManagementManagement

William L. White, MA William L. White, MA Chestnut Health SystemsChestnut Health Systems

Bloomington, IL USABloomington, IL USAEmail: bwhite@chestnut.orgEmail: bwhite@chestnut.org

Presentation Goals Presentation Goals

1.1. Describe the contextual forces that are Describe the contextual forces that are triggering the call for a fundamental triggering the call for a fundamental redesign of addiction treatment redesign of addiction treatment

2.2. Outline how service philosophies and Outline how service philosophies and practices are changing within practices are changing within “Recovery-Oriented Systems of Care” “Recovery-Oriented Systems of Care” (ROSC)(ROSC)

New Monographs New Monographs

White, W. (2008). White, W. (2008). Recovery management Recovery management and recovery-oriented systems of care: and recovery-oriented systems of care: Scientific rationale and promising Scientific rationale and promising practicespractices. See www.ireta.org. See www.ireta.org

White, W. (2009). White, W. (2009). Peer-based addiction Peer-based addiction recovery support: History, theory, recovery support: History, theory, practice, and scientific evaluation. See practice, and scientific evaluation. See www.glattc.org. www.glattc.org.

Recovery Revolution Recovery Revolution DefinedDefined1. Cultural/political awakening of 1. Cultural/political awakening of

communities of recoverycommunities of recovery2. Emergence of recovery as an 2. Emergence of recovery as an

organizing paradigm for behavioral organizing paradigm for behavioral healthcarehealthcare

3. Call for fundamental changes in the 3. Call for fundamental changes in the design of addiction treatment: design of addiction treatment: Toward “Recovery Management” and Toward “Recovery Management” and “Recovery-oriented Systems of Care”“Recovery-oriented Systems of Care”

Recovery Mutual Aid Recovery Mutual Aid SocietiesSocieties• Growth in size and geographical dispersionGrowth in size and geographical dispersion• Philosophical diversification (religious, Philosophical diversification (religious,

spiritual, secular; moderation-based)spiritual, secular; moderation-based)• Group specialization by drug choice, age, Group specialization by drug choice, age,

gender, sexual orientation, occupation and gender, sexual orientation, occupation and co-occurring problems co-occurring problems

• Growing “varieties of recovery experience”Growing “varieties of recovery experience”

Sources: White & Kurtz, 2006, Sources: White & Kurtz, 2006, International Journal of International Journal of Self Help and Self CareSelf Help and Self Care; White, 2004, ; White, 2004, Addiction; Addiction; Humphreys, 2004, Humphreys, 2004, Circles of RecoveryCircles of Recovery. .

Recovery Community: Recovery Community: Institution BuildingInstitution Building

• Recovery Community Organizations Recovery Community Organizations

• Recovery Homes and ColoniesRecovery Homes and Colonies

• Recovery SchoolsRecovery Schools

• Recovery IndustriesRecovery Industries

• Recovery Ministries/ChurchesRecovery Ministries/Churches

• Recovery Community Centers, Recovery Recovery Community Centers, Recovery Social Clubs, Recovery CafesSocial Clubs, Recovery Cafes

Source: White, 2008, Source: White, 2008, CounselorCounselor..

Recovery Community: Cultural Recovery Community: Cultural DevelopmentDevelopment

Cultural Consciousness Related to:Cultural Consciousness Related to:• HistoryHistory• Language Language • ValuesValues• Rituals of CelebrationRituals of Celebration• Literature, Music, Cinema, ArtLiterature, Music, Cinema, Art

Source: White, 1996, Source: White, 1996, Culture of Addiction, Culture of Addiction, Culture of RecoveryCulture of Recovery

New Recovery Advocacy New Recovery Advocacy MovementMovementPolitical awakening of people in recoveryPolitical awakening of people in recovery• Recovery SummitsRecovery Summits• New and Renewed Recovery Advocacy New and Renewed Recovery Advocacy

OrganizationsOrganizations• Kinetic IdeasKinetic Ideas• Advocacy and Anti-stigma CampaignsAdvocacy and Anti-stigma Campaigns• Recovery Month and Recovery Celebration Recovery Month and Recovery Celebration

Events (40,000+ US participants in Sept., Events (40,000+ US participants in Sept., 2008)2008)

Source: White, 2007, Source: White, 2007, AddictionAddiction. .

Toward a Recovery Toward a Recovery ParadigmParadigmFrom Pathology (knowledge drawn from From Pathology (knowledge drawn from

studies of addiction) and Intervention studies of addiction) and Intervention Paradigms (knowledge drawn from studies Paradigms (knowledge drawn from studies of treatment) to a Recovery Paradigm of treatment) to a Recovery Paradigm (knowledge drawn from collective (knowledge drawn from collective experience & study of long-term recovery) experience & study of long-term recovery)

Call for “Recovery-Oriented Systems of Care”Call for “Recovery-Oriented Systems of Care”

Source: White, 2005, Source: White, 2005, Alcoholism Treatment Alcoholism Treatment Quarterly; Quarterly; Clark, 2007; Kirk, 2007; Evans, Clark, 2007; Kirk, 2007; Evans, 20072007

Two Prevailing Models of Two Prevailing Models of Addiction TreatmentAddiction Treatment

1.1. Acute care model that focuses on Acute care model that focuses on brief biopsychosocial stabilization brief biopsychosocial stabilization without sustained recovery support.without sustained recovery support.

2.2. Chronic care model that began with Chronic care model that began with a vision of comprehensive a vision of comprehensive rehabilitation for chronic heroin rehabilitation for chronic heroin dependencedependence

The Acute Care ModelThe Acute Care Model

• An encapsulated set of specialized service An encapsulated set of specialized service activities (assess, admit, treat, discharge, activities (assess, admit, treat, discharge, terminate the service relationship).terminate the service relationship).

• A professional expert drives the process.A professional expert drives the process.• Services transpire over a short (and ever-Services transpire over a short (and ever-

shorter) period of time.shorter) period of time.• Individual/family/community are given Individual/family/community are given

impression at discharge (“graduation”) that impression at discharge (“graduation”) that recovery is now self-sustainable without recovery is now self-sustainable without ongoing professional assistance ongoing professional assistance

Source: White & McLellan, 2008, Counselor Source: White & McLellan, 2008, Counselor

The Chronic Care ModelThe Chronic Care Model

Vision: medication-assisted metabolic stabilization Vision: medication-assisted metabolic stabilization for chronic opioid dependence as a foundation for chronic opioid dependence as a foundation for long-term biopsychosocial recovery for long-term biopsychosocial recovery

Model Deterioration: dosing with inadequate Model Deterioration: dosing with inadequate clinical & peer recovery support for psychosocial clinical & peer recovery support for psychosocial rehabilitation and & community re-integrationrehabilitation and & community re-integration

Focus: what is subtracted/reduced (drug-related Focus: what is subtracted/reduced (drug-related problems, crime, disease risk/transmission) from problems, crime, disease risk/transmission) from client’s life rather than what is added (e.g., client’s life rather than what is added (e.g., global personal/family health, productivity, life global personal/family health, productivity, life meaning/purpose, citizenship and service) meaning/purpose, citizenship and service)

““Treatment Works” Treatment Works”

Efficacy and effectiveness established via Efficacy and effectiveness established via enhanced outcomes compared to no enhanced outcomes compared to no treatment or non-specialized treatmenttreatment or non-specialized treatment

Lives of many individuals and families Lives of many individuals and families transformed through the medium of transformed through the medium of addiction treatmentaddiction treatment

Effectiveness influenced by problem severity Effectiveness influenced by problem severity and complexity and recovery capitaland complexity and recovery capital

Source: Review in White, 2008 MonographSource: Review in White, 2008 Monograph

Existing Treatment Works, Existing Treatment Works, But….But….• Weak attraction (less than 10% in any Weak attraction (less than 10% in any

year; 25% in lifetime)year; 25% in lifetime)• Delayed engagement (late stage & Delayed engagement (late stage &

primarily through external coercion)primarily through external coercion)• Compromised access (waiting lists & other Compromised access (waiting lists & other

obstacles)obstacles)• High attrition following Admission (more High attrition following Admission (more

than 50%)than 50%)• Inadequate dose/duration (less than dose Inadequate dose/duration (less than dose

linked to best recovery outcomes) linked to best recovery outcomes)

Existing Treatment Works, Existing Treatment Works, But…But…• Inadequate quality (limited in scope of Inadequate quality (limited in scope of

services and by methods lacking scientific services and by methods lacking scientific support) support)

• Passive rather than assertive linkage to Passive rather than assertive linkage to communities of recovery & high attritioncommunities of recovery & high attrition

• Inadequate post-treatment continuing care Inadequate post-treatment continuing care (received by only 10-20% of clients) (received by only 10-20% of clients)

• High rates (50%+) of post-treatment relapse High rates (50%+) of post-treatment relapse (most within 90 days of discharge) & high re-(most within 90 days of discharge) & high re-admission rates (25-35% within one year)admission rates (25-35% within one year)

Existing Treatment Works, Existing Treatment Works, But…But…

• In the U.S, 64% of clients admitted to In the U.S, 64% of clients admitted to addiction treatment have one or more prior addiction treatment have one or more prior treatment episodes; 19% have 5 or more treatment episodes; 19% have 5 or more prior episodesprior episodes

• We are placing people in treatment whose We are placing people in treatment whose design is incapable of generating design is incapable of generating sustainable recovery for many clients & then sustainable recovery for many clients & then blaming the clients for that failure. blaming the clients for that failure.

Sources: White, 2008 MonographSources: White, 2008 Monograph

Toward a Model of Sustained Toward a Model of Sustained Recovery Management (RM)Recovery Management (RM)

• Pre-recovery identification and engagementPre-recovery identification and engagement• Recovery initiation and stabilizationRecovery initiation and stabilization• Sustained support for recovery maintenance Sustained support for recovery maintenance • Support for enhanced quality of Support for enhanced quality of

personal/family life in long-term recoverypersonal/family life in long-term recovery --Emphasis on peer-based recovery support --Emphasis on peer-based recovery support

services and indigenous community supportservices and indigenous community supportSource: White, 2009, Journal of Substance Source: White, 2009, Journal of Substance

Abuse TreatmentAbuse Treatment

Recovery Management:Recovery Management:Emerging Elements Emerging Elements

• Recovery orientation, e.g., mission, Recovery orientation, e.g., mission, representation, service philosophyrepresentation, service philosophy

• Early engagement, e.g., assertive Early engagement, e.g., assertive community outreachcommunity outreach

• Increased access & retention, e.g., Increased access & retention, e.g., streamlined intake, in-Tx recovery streamlined intake, in-Tx recovery coaching and support servicescoaching and support services

• Assessments that are global, strength-Assessments that are global, strength-based & continualbased & continual

Recovery Management:Recovery Management:Emerging ElementsEmerging Elements

• Rapid transition from treatment Rapid transition from treatment planning to recovery planning / choice planning to recovery planning / choice philosophyphilosophy

• Expanded service team, e.g., inclusion Expanded service team, e.g., inclusion of primary physicians, “indigenous of primary physicians, “indigenous healers,” recovery volunteershealers,” recovery volunteers

• Assertive linkage to communities of Assertive linkage to communities of recoveryrecovery

Recovery Management:Recovery Management:Emerging ElementsEmerging Elements• Assertive approaches to continuing care Assertive approaches to continuing care

(e.g., recovery checkups) for up to 5 years(e.g., recovery checkups) for up to 5 years• Shift in helping role/relationship from expert Shift in helping role/relationship from expert

to recovery consultant/partnershipto recovery consultant/partnership• Focus on building personal, family & Focus on building personal, family &

community recovery capital, e.g. community community recovery capital, e.g. community development strategiesdevelopment strategies

• Evaluation based on effects of multiple Evaluation based on effects of multiple interventions on long-term interventions on long-term addiction/treatment/recovery careers rather addiction/treatment/recovery careers rather than immediate effects of single than immediate effects of single intervention intervention

Closing ThoughtsClosing Thoughts

1. ROSC and RM represent not a refinement 1. ROSC and RM represent not a refinement of modern addiction treatment, but a of modern addiction treatment, but a fundamental redesign of such treatment.fundamental redesign of such treatment.

2. Overselling what existing treatment 2. Overselling what existing treatment models can achieve to policy makers and models can achieve to policy makers and the public risks a backlash and the the public risks a backlash and the revocation of addiction treatment’s revocation of addiction treatment’s probationary status as a cultural probationary status as a cultural institution. institution.

Closing ThoughtsClosing Thoughts

3. It will take years to transform addiction 3. It will take years to transform addiction treatment into a model of sustained treatment into a model of sustained recovery support.recovery support.

4. That process will require replicating what 4. That process will require replicating what is already underway in many locations: is already underway in many locations: aligning concepts, contexts (infrastructure, aligning concepts, contexts (infrastructure, policies and system-wide relationships) policies and system-wide relationships) and service practices to support long-term and service practices to support long-term recovery for individuals and families. recovery for individuals and families.