Recovery Management:
History, Science & Changes in
Clinicial Practices
William L. White, M.A.
ROSC Symposium
Atlanta, GA July 21-22
Presentation Goals
1. Highlight the emergence of recovery as an
organizing paradigm for the addiction treatment
field
2. Outline how frontline service practices are
changing as systems of care & local addiction
treatment programs shift from an acute care
(AC) model of intervention to a model of
sustained recovery management (RM)
Perspective
• 40 years in treatment field
• Work in addictions research institute for past 22
•
•
years
Consultant to pioneer ROSC/RM implementation
sites, e.g., CT and Philadelphia
Work with recovery community organizations on
development of P-BRSS via & RCSP & ATR sites,
e.g., Recovery Consultants of Atlanta
A Recovery Revolution?
• Growth & Diversification of American
•
•
•
•
Communities of Recovery
Recovery Community Institution Building*
A New Recovery Advocacy Movement*
Calls to Reconnect Treatment to the More
Enduring Process of Personal/Family Recovery*
Shift from Pathology and Intervention Paradigms
to a Recovery Paradigm*
White, 2004, 2005, 2006, 2007, in press
Recovery Community Building
• Growth and diversification of recovery mutual
•
•
•
•
•
•
aid groups
Recovery Community Organizations
Recovery Homes
Recovery Schools
Recovery Industries
Recovery Ministries/Churches
Cultural Development Source: White, 2008,
2009
Science & New Recovery
Support Institutions
There is a growing body of evidence that
enmeshing clients with high problem
severity and low recovery capital within
sober living communities can
dramatically enhance long-term
recovery outcomes. (Jason,Davis,
Ferrari& Bishop,2001), e.g. Oxford
House : 50% less relapse, twice
monthly income, 1/3 incarceration
Advocacy Vision Versus Reality
Recovery
Treatment
TX
Recovery
Vision 1963-1970
Reality 2009
Signs of a Paradigm Shift
• Science-based conceptualizations of addiction as
•
•
•
a chronic disorder (Hser, et al, 1997; McLellan et
al, 2000; Dennis & Scott, 2007)
Accumulation of systems performance data on
limitations of acute care (AC) model of addiction
treatment (White, 2008)
Recovery as an organizing construct for
behavioral health care policies & programs (e.g.,
IOM, 2006; CSAT’s RCSP & ATR programs)
“Recovery-focused systems transformation”
efforts (Clark, 2007; Kirk, 2007; Evans, 2007)
Signs of a Paradigm Shift
• Calls for a recovery-focused research agenda
•
(White, 2000; White & Godley, 2007, White &
Chaney, 2009; White & Schulstad, in press)
A new and newly nuanced language, e.g., efforts
to define recovery, recovery-oriented systems of
care (ROSC), and recovery management (RM)
(e.g., Journal of Substance Abuse Treatment
23(3), 2007)
Recovery Research
New Resources
• The Varieties of Recovery Experience (White &
Kurtz, 2006)
• Linking Addiction Treatment & Communities of
Recovery Support: A Primer for Addiction
Counselors & Recovery Coaches (White & Kurtz,
2006)
• Peer Recovery Support: History, Theory, Science
& Practice (White, 2009)
AOD PROBLEMS
Etiology
Pattern
Treatment
Recovery
Clinical Versus Community
Populations
1. Higher personal vulnerability (e.g., family
history, lower age of onset, victimization)
2. Higher severity (acuity & chronicity)
3. Higher rates of co-morbidity
4. Greater personal and environmental
obstacles to recovery
5. Lower recovery capital (personal assets /
family and social supports)
Family History and ATOD
Vulnerability
• Genetic Risks
• Problem Severity and Chronicity
• Breaking Intergenerational Cycles of ATOD
Dependence (See White & Chaney, 2009)
Age of Onset of Use & Personal
Vulnerability
•
•
•
•
•
•
•
Risk of adult SUD
Speed of problem development
Problem severity
Problem complexity (e.g., psychiatric comorbidity)
Treatment Prognosis
Duration of addiction career
Mortality (e.g., involvement in alcohol-related
crash)
Traumagenic Factors
•
•
•
•
•
•
•
Age of Onset
Duration
Number of Incidents; Number of Perpetrators
Relationship of Perpetrators to the Family
Physical Violence
Types of Abuse
Response to Breaking Silence (Titus, et al, 2003)
Recovery Capital
Recovery capital is the quantity and quality
of internal and external resources that
can be mobilized to initiate and sustain
long-tern addiction recovery (Granfield
and Cloud, 1999).
What is Recovery?
•
•
•
•
•
Sustained Abstinence--Primary Drug
Sustained Abstinence--No Drug Substitution
Reduction of Drug use to Subclinical Levels
Sustained Absence of Drug-related Problems
Resolution of AOD Problems within the
Umbrella of Global Health
(White, 2008)
Emerging Definition
1. Sobriety
2. Global Health
3. Citizenship
Journal of Substance Abuse Treatment
Special Issue 33(3), including Betty Ford
Consensus Panel, 2008; White, 2008
Types of Recovery
1. Abstinence-based Recovery
2. Moderated Recovery/Resolution
--Prevalence increases as problem severity
declines
3. Medication-assisted Recovery
White & Kurtz, 2006
Medication Assisted Recovery
• Aversive Agents
– Disulfram (Antabuse)
• Maintenance Agents
– Methadone and LAAM
– Buprenorphine
• Anti-craving Agents
– Naltrexone (Revia) and Acamprosate
Medication and Recovery Status
Emerging View:
“formerly opioid-dependent individuals who
take naltrexone, buprenorphine, or
methadone as prescribed and are
abstinent from alcohol and all other
nonprescribed drugs would meet this
definition of sobriety.” 2008 Betty Ford
Consensus Panel
Recovery Prevalence
Studies of people meeting lifetime criteria for
a DSM-IV Substance Use Disorder in
community and treatment samples reveal
that 58-60% eventually achieve sustained
recovery (i.e., no dependence or abuse
symptoms for the past year). (Kessler,
1994; Dawson, 1996; Robins & Regier,
1991; Dennis et al, 2005)
Depth of Recovery
1. Full Recovery
2. Partial Recovery
3. Amplified (Transcendent) Recovery
Styles of Recovery
Interpersonal Style
– Acultural
– Bicultural
– Culturally Enmeshed
Variations in Personal Identity
– Recovery Positive Identity
– Recovery Neutral Identity
– Recovery Negative Identity
4 Overlapping Styles of Recovery
• Professionally Assisted
• Solo (Natural) Recovery
• Affiliated Recovery
• Disengaged Recovery
White & Kurtz, 2006
Gender Factors In Recovery
Initiation
• Pregnancy
• Parenthood
• Fear of Effects of AOD use on Children
• Fear of Losing Custody of Children
• Separating from an Addicted Partner
(Chen and Kandell, 1998; Burman, 1997)
Family Recovery (Brown &
Lewis)
“While recovery alleviates many of the family’s
historical problems, this early period can also be
referred to as the “trauma of recovery”: a time
of great change, uncertainty and turmoil.”
“The unsafe, potentially out-of-control
environment continues as the context for family
life into the transition and early recovery
stages...as long as 3-5 years.”
Family Recovery Principles
• Family members may need support
structures to serve as “holding
environments” until a healthier family
system can be constructed.
• Without such supports, personal recovery
may produce family disintegration.
• This change process can last for 5-10
years.
Recovery-oriented Systems of Care
Recovery-oriented systems of care (ROSC)
are networks of formal and informal
services developed and mobilized to
sustain long-term recovery for individuals
and families impacted by severe substance
use disorders. The system in ROSC is not
a treatment agency but a macro level
organization of a community, a state or a
nation.
Recovery Management
“Recovery management” (RM) is a philosophical
framework for organizing addiction treatment
services to provide pre-recovery identification
and engagement, recovery initiation and
stabilization, long-term recovery maintenance,
and quality of life enhancement for individuals
and families affected by severe substance use
disorders.
Recovery Management & Stages of
Recovery
1. Pre-recovery identification and
engagement (recovery priming)
2. Recovery initiation and stabilization
3. Transition to successful recovery
maintenance
4. Enhancement of quality of
personal/family life in long-term recovery
Rhetoric Versus Reality
1. Policy statements for more than 200 years have
referred to addiction as a “chronic” disorder.
2. Research data just reviewed supports that
contention.
3. But we’ve never really believed it.
4. Addiction treated like it was a broken arm rather
than a condition such as diabetes or heart
disease requiring sustained monitoring and
care.
Addiction/Chronic Illness
Compliance
Rate (%)
Relapse Rate
(%)
Alcohol
30-50
50
Opioid
30-50
40
Cocaine
30-50
45
Nicotine
30-50
70
Medication
<50
30-50
Diet and Foot Care
<50
30-50
Medication
<30
50-60
Diet
<30
50-60
<30
60-80
Addiction/Chronic Illness
Insulin Dependent Diabetes
Hypertension
Asthma
Medication
O’Brien CP, McLellan AT. Myths about the Treatment of Addiction
(1996). The Lancet, Volume 347(8996), 237-240.
Severe substance dependence and
other chronic illnesses:
• Are influenced by multiple personal, family
and environmental risk factors.
• Are influenced by voluntary choices that
become potentially less voluntary over
time via neurobiological changes in the
brain.
• Have a prolonged course that varies from
person to person.
Substance Use Careers Last for Decades
100%
90%
80%
70%
Median
duration of
27 years
(IQR: 18 to
30+)
Percent in Recovery
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271)
Most people who develop abuse/dependence
Have substance related problems for years
1.00
AOD (median=12 years)
.90
Alcohol (median=10 years)
Percent with Problems
.80
Drugs (median=6 years)
.70
Once they have abuse or
dependence, over half
will have 12 or more
years of AOD problems
.60
.50
.40
.30
.20
.10
.00
0
5
10
15
20
25
Years of SUD Problems from Age of 1st Problems
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
30
It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%
Percent in Recovery
70%
Median duration
of 9 years
and 3 to 4
episodes of care
60%
50%
40%
30%
20%
10%
0% 0
5
10
15
20
Years from first Tx to 1+ years abstinence
25
Source: Dennis et
al 2005 (n=1,271)
Severe substance dependence and
other chronic illnesses:
• Are accompanied by risks of profound
pathophysiology, disability and premature
death.
• Have effective treatments, selfmanagement protocols, peer support
frameworks and similar remission rates,
but no known cures. (White & McLellan,
2008)
If we really believed addiction was a
chronic disorder, we would not:
1. Create expectation that full recovery should be
achieved from a single Tx episode
(Demoralization of clients/families, staff, policy
makers, community)
2. View prior Tx as indicative of poor prognosis
3. Extrude clients for becoming symptomatic
(confirming their diagnosis)
If we really believed addiction was a
chronic disorder, we would not:
4. Treat addiction in serial episodes of disconnected
TX
5. Relegate aftercare to an afterthought
6. Terminate the service relationship following brief
intervention
The Prevailing 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 is given impression
at discharge (“graduation”) that recovery is now
self-sustainable without ongoing professional
assistance (White & McLellan, 2008).
Treatment (Acute Care Model)
Works!
Post-Tx remissions one-third, AOD use
decreases by 87% following Tx, &
substance-related problems decrease by
60% following Tx (Miller, et al, 2001).
Lives of individuals and families transformed
by addiction treatment.
Treatment Works, BUT…
AC & RM Model Review
Comparison on 10 key dimensions of service
design and performance
• AC Model Vulnerability
• How RM Models are Addressing Each
Area of Vulnerability
1. AC Model Vulnerability:
Attraction
Only 10% of those needing treatment
received it in 2002 (Substance Abuse and
Mental Health Services Administration,
2003); only 25% will receive such services
in their lifetime (Dawson, et al, 2005).
Why People Who Need it Don’t
Seek Treatment
• Perception of the Problem, e.g., isn’t that
•
•
•
bad.
Perception of Self, e.g., should be able to
handle this on my own.
Perception of Treatment, e.g., ineffective,
unaffordable, inaccessible or “for losers”
Perception of Others, e.g., fear of stigma
and discrimination
Source: Cunningham, et, al, 1993; Grant 1997
Coercion vs. Choice
The majority of people who do enter
treatment do so at late stages of problem
severity/complexity and under external
coercion (SAMHSA, 2002).
The AC model does not voluntarily attract
the majority of individuals who meet
diagnostic criteria for a substance use
disorder.
RM Model Strategy:
Attraction
• Recovery-focused anti-stigma campaigns, e.g.,
•
•
•
Recovery is Everywhere campaign, Ann Arbor, MI
Early screening & brief intervention programs
Assertive models of community outreach
Non-stigmatized service sites, e.g., hospitals &
health clinics, workplace, schools, community
centers
Principle: Earlier the screening, diagnosis & Tx
initiation, the better the prognosis for long-term
recovery
2. AC Model Vulnerability:
Access & Engagement
Access to treatment is compromised by
waiting lists (Little Hoover Commission,
2003).
High waiting list dropout rates (25-50%)
(Hser, et al, 1998; Donovan et al, 2001).
Special obstacles to treatment access for
some populations (e.g., women) (White &
Hennessey, 2007)
Weak Engagement & Attrition
Dropout rates between the call for an appointment
at an addiction treatment agency and the first
treatment session range from 50-64% (Gottheil,
Sterling & Weinstein, 1997).
Nationally, more than half of clients admitted to
addiction treatment do not successfully complete
treatment (48% “complete”; 29% leave against
staff advice; 12% are administratively
discharged for various infractions; 11% are
transferred) (OAS/SAMHSA 2005).
High Extrusion as a Motivational
Filter
High AMA and AD rates constitute a form of
“creaming” e.g., view that “Those who really
want it will stay.”
The reality: those least likely to complete are not
those who want it the least, but those who need
it the most—those with the most severe &
complex problems, the least recovery capital,
and the most severely disrupted lives (Stark,
1992; Meier et al, 2006).
RM Model Strategy:
•
•
•
•
•
•
•
Assertive waiting list management
Streamlined intake
Lowered thresholds of engagement
Pain-based (push force) to hope-based (pullforce) motivational strategies
Appointment prompts & phone follow-up of
missed appointments
Institutional outreach for regular re-motivation
Radically altered AD polices (White, 2008;
White, et al, 2005)
100%
90%
21+
80%
15-20*
70%
Percent in Recovery
60%
under 15*
50%
40%
Age of 1st Use Groups
Substance Use Careers are Longer,
the Younger the Age of First Use
30%
20%
10%
0%
* p<.05
(different
from 21+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271)
100%
90%
0-9*
80%
10-19*
70%
Percent in Recovery
60%
50%
40%
20+
Years to 1st Tx Groups
Substance Use Careers are Shorter
the Sooner People get to Treatment
30%
20%
10%
0%
* p<.05 (different
from 20+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271)
Altered View of Motivation
Motivation seen as important, but as an outcome
of a service process, not a pre-condition for
entry into treatment. A strong therapeutic
relationship can overcome low motivation for
treatment and recovery (Ilgen, et al, 2006).
Motivation for change no longer seen as sole
province of individual, but as a shared
responsibility with the treatment team, family
and community institutions (White, Boyle &
Loveland, 2003).
3. AC Model Vulnerability:
Assessment & Tx Planning
• Categorical
• Pathology-focused, e.g., problem list to
treatment plan
• Unit of assessment is the individual
• Professionally-driven
• Intake function
RM Model Strategy: Assessment &
Recovery Planning
• Global rather than categorical (e.g., ASI, GAIN)
• Strengths-based (emphasis on assessment of
•
•
•
•
recovery capital) (Granfield & Cloud, 1999)
Greater emphasis on self-assessment versus
professional diagnosis
Scope of assessment includes individual, family
and recovery environment
Continual rather than intake activity
Rapid transition from Tx plans to recovery plans
(Borkman, 1998)
4. AC Model Vulnerability:
Service Elements
• Widespread use of approaches that lack
scientific evidence for their efficacy and
effectiveness (in spite of recent advances)
• Minimal individualization of care, e.g.,
reliance on going through the “program”
• Only superficial responsiveness to special
needs, e.g., specialty appendages rather
than system-wide changes
RM Model Strategy:
Service Elements
• Emphasis on evidence-based, evidence-informed
•
•
& promising practices
High degree of individualization, e.g. from
“programs” to service menus whose elements
are uniquely combined, sequenced &
supplemented
Emphasis on mainstream services that are
gender-specific, culturally competent,
developmental appropriate, and traumainformed
5. AC Model Vulnerability:
Composition of Service Team
AC Model often uses medical (disease)
metaphors but utilizes a service team
made up almost exclusively of nonmedical personnel.
AC model uses a recovery rhetoric but
representation of recovering people in Tx
milieu via staff and volunteers has
declined via professionalization.
RM Model Strategy:
Composition of Service Team
• Increased involvement of primary care
•
•
•
•
physicians
New service roles, e.g., recovery coaches
Utilization of new service organizations, e.g.
community recovery centers (White & Kurtz,
2006; Valentine, White & Taylor, 2007)
Renewed emphasis on volunteer programs,
consumer councils/ alumni associations
Inclusions of “indigenous healers” in
multidisciplinary teams, e.g., faith community
Recovery Coach / Community
Guide
• Knowledgeable of about indigenous and
•
•
•
•
formal community resources
Capable of engaging the difficult-to-engage
person
Skilled at leading people into relationship with
a recovering community
Skilled at sustaining long-term recovery
support relationships
Skilled at organizing resources where none
exist
The Recovery Coach /
Community Guide:
• Sees possibilities where others see only
•
•
•
•
problems.
Is personally connected to the “communities
within the community”
Can make things happen because they are
trusted within these communities.
Believes the community is a “reservoir of
untapped hospitality”
Knows an individual’s engagement with the
community begins when the guide leaves.
(McKnight, 1995)
6. AC Model Vulnerability: Locus of
Service Delivery
• Institution-based
• Weak understanding of physical and
cultural contexts in which people are
attempting to initiate recovery
• AC Model question: “How do we get the
individual into treatment”--get them from
their world to our world?
RM Strategy:
Locus of Service Delivery
• Home-, neighborhood- & community-
based
• RM question: “How do we nest recovery in
the natural environment of this individual
or create an alternative recoveryconducive environment?”
• “Healing Forest” metaphor; concept of
treating the community
7. AC Model Vulnerability:
Service Dose and Duration
One of the best predictors of treatment
outcome is service dose (Simpson, et al,
1999). Many of those who complete
treatment receive less than the optimum
dose of treatment recommended by the
National Institute on Drug Abuse (NIDA,
1999; SAMHSA, 2002)
AC Model Vulnerability: Frequency
of Discharge, Relapse, Readmission
The majority of people completing addiction
treatment resume AOD use in the year following
treatment (Wilbourne & Miller, 2002).
Of those who consume alcohol and other drugs
following discharge from addiction treatment,
80% do so within 90 days of discharge
(Hubbard, Flynn, Craddock, & Fletcher, 2001).
Recovery/Relapse Patterns
Over Twelve Months
Sustained
Recovery
9%
Later
Sustained
Recovery
15%
Continous
Problems
40%
Intermittent In Recovery
7%
Intermittent Problems
29%
Clinical Research
(Treatment Outcome Studies)
• Sustained symptom suppression
• Symptom continuation (no measurable
effect of treatment)
• Early suppression followed by clinical
deterioration
• Early deterioration followed by sustained
symptom suppression
• Cycles of suppression and deterioration
Fragility of Early Recovery
Individuals leaving addiction treatment are fragilely
balanced between recovery and re-addiction in
the hours, days, weeks, months, and years
following discharge (Scott, et al, 2005).
Recovery and re-addiction decisions are being
made at a time that we have disengaged from
their lives, but that many sources of recovery
sabotage are present.
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery (Pathway Adults)
Over half change
status annually
P not the same in
both directions
Incarcerated
(37% stable)
6%
7%
25%
30%
In the
Community
Using
(53% stable)
13%
8%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott, Dennis, & Foss (2005)
7%
Treatment is the
most likely path
to recovery
AC Model Vulnerability: Failure to
Manage Addiction/Tx/Recovery
Careers
Most persons treated for substance
dependence who achieve a year of stable
recovery do so after multiple episodes of
treatment over a span of years (Anglin, et
al, 1997; Dennis, Scott, & Hristova, 2002).
AC Model Vulnerability: Timing of
Recovery Stability
Durability of alcoholism recovery (the point
at which risk of future lifetime relapse
drops below 15%) is not reached until 4-5
years of remission (Jin, et al, 1998).
20-25% of narcotic addicts who achieve five
or more years of abstinence later return to
opiate use (Simpson & Marsh, 1986; Hser
et al, 2001).
Reminder: Fragility of Family
Recovery
“While recovery alleviates many of the family’s
historical problems, this early period can also be
referred to as the “trauma of recovery”: a time
of great change, uncertainty and turmoil.”
“The unsafe, potentially out-of-control
environment continues as the context for family
life into the transition and early recovery
stages...as long as 3-5 years.”
Source: Brown & Lewis, 1999
“Aftercare” as an Afterthought
Post-discharge continuing care can enhance
recovery outcomes (Johnson & Herringer, 1993;
Godley, et al, 2001; Dennis, et al, 2003).
But only 1 in 5 (McKay, 2001) to 1 in 10 (OAS,
SAMHSA, 2005) adult clients receive such care
(McKay, 2001) and only 36% of adolescents
receive any continuing care (Godley,et al, 2001)
AC Treatment as the New Revolving
Door
Of those admitted to the U.S. public
treatment system in 2003, 64% were reentering treatment including 23%
accessing treatment the second time, 22%
for the third or fourth time, and 19% for the
fifth or more time (OAS/SAMHSA, 2005).
RM Model Strategy: Assertive
Approaches to Continuing Care
• Post-treatment monitoring & support (recovery
•
•
•
•
checkups)
Stage-appropriate recovery education &
coaching
Assertive linkage to communities of recovery
If & when needed, early re-intervention & relinkage to Tx and recovery support groups
Focus not on service episode but managing the
course of the disorder to achieve lasting
recovery.
RM Model Strategy: Assertive
Approaches to Continuing Care
1. Provided to all clients not just those who
“graduate”
2. Responsibility for contact: Shifts from
client to the treatment
organization/professional
RM Model Strategy: Assertive
Approaches to Continuing Care
3. Timing: Capitalizes on critical windows of
vulnerability (first 30-90 days following Tx)
and power of sustained monitoring
(Recovery Checkups)
4. Intensity: Ability to individualize
frequency and intensity of contact based
on clinical data
RM Model Strategy: Assertive
Approaches to Continuing Care
5. Duration: Continuity of contact over time with a
primary recovery support specialist for up to 5
years
6. Location: Community-based versus clinic-based
7. Staffing: May be provided in a professional or
peer-based delivery format
8. Technology: Increased use of telephone- &
Internet-based support services
Post-Treatment Recovery
Coaching
•
•
•
•
•
•
•
Encourage Self-monitoring
Recovery Checkups
Feedback
Stage-Appropriate Recovery Education
Resource Linkage (Indigenous)
Early Re-intervention (Treatment)
Re-engagement and Recovery Priming Following
Broken Contact
Dennis, Scott & Funk Chicago
Adult Study (2003)
Effect of Recovery Management Checkups
on Cycle
Sample: 448 individuals randomly
assigned to receive over 2 yrs either
quarterly assessment interviews or
quarterly recovery management
(assessment with re-intervention and
linkage to Tx)
Recovery Management
Checkups
Study Findings
Those assigned to RMC more likely to return
to Tx sooner, spend more days in Tx, &
less likely to be in need of Tx at 24
months
Godley, Godley, Dennis, et al,
Adolescent Study (2002)
Sample: 114 adolescents discharged from
IP Tx randomly assigned to aftercare as
usual or assertive continuing care (ACC)
ACC Intervention: Home visits, sessions for
adolescents, parents and joint sessions,
case management
Effects of Assertive Continuing
Care
Findings at 3 months
1. ACC group had a higher engagement/retention
rate (94%)
2. ACC group averaged more than twice the
continuing care sessions as the control group
3. ACC group showed lower relapse rates for
alcohol and cannabis; days to first use longer
in ACC group members who did use
8. AC Model Vulnerability:
Relationship with Recovery
Communities
Participation in peer-based recovery support
groups (AA/NA, etc.) is associated with improved
recovery outcomes (Humphreys et al, 2004).
This finding is offset by low Tx to community
affiliation rates and high (35-68%) attrition in
participation rates in the year following
discharge (Makela, et al, 1996; Emrick, 1989)
Passive/Active Linkage
Active linkage (direct connection to mutual
aid during treatment) can increase
affiliation rates (Weiss, et al 2000),
But studies reveal most referrals from
treatment to mutual aid are passive
variety (verbal suggestion only)
(Humphreys, et al 2004)
Mutual Aid and Special
Populations
• Early Criticisms
• Women and people of color affiliate with
•
AA/NA at the same rates as white men
(Humphreys, 1994; Kessler, et al, 1997;
Winzelberg and Humphreys, 1999)
Over time, participation in AA for African
Americans and Hispanics decreases (Tonigan,
et al, 1998); This may reflect a transfer of
recovery maintenance to indigenous
institutions.
RM Model Strategy
• Staff & volunteers knowledgeable of multiple
•
•
pathways/styles of long-term recovery, local
recovery community resources and Online
recovery support meetings and related services
(White & Kurtz, 2006)
Direct relationship with H & I committees and
comparable service structures
Recovery coaches provide assertive linkages to
support groups and larger communities of
recovery
9. AC Model:
Service Relationship
Dominator-Expert Model: Recovery is
based on relationships that are
hierarchical, time-limited, transient and
commercialized.
RM Model:
Service Relationship
Partnership Model: Recovery is based on
imbedding the client/family in recovery
supportive relationships that are natural,
reciprocal, enduring, and noncommercialized.
RM is focused on continuity of contact in a
recovery supportive service relationship over
time comparable to role of primary physician.
--Will require stabilization of field’s workforce
Philosophy of Choice / Consultation Role
10. AC Model Vulnerability:
Evaluation
Historical focus on measurement of shortterm outcomes of a single episode of care
at a single point in time following
treatment; outcome is measured by
pathology reduction.
RM Model Strategy:
Evaluation
• Focus on effect of interventions on
•
•
•
addiction/treatment/recovery careers at multiple
points in time (McLellan, 2002)
Focus on long-term recovery processes and
quality of life in recovery.
Greater involvement of clients, families &
community elders in design, conduct and
interpretation of outcome studies (White &
Sanders, 2008).
Search for potent service combinations and
sequences.
Closing Thoughts
1. ROSC and RM represent not a refinement
of modern addiction treatment, but a
fundamental redesign of such treatment.
2. Overselling what the AC model 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 from an AC model of intervention to a
RM model of sustained recovery support.
4. That process will require replicating across the
country what is already underway in the City of
Philadelphia: aligning concepts, contexts
(infrastructure, policies and system-wide
relationships) and service practices to support
long-term recovery.