Reflections on recovery – From seven years ago

2007_0116walpole0008This is from the website Articles section. Thought you should see how I was thinking seven years ago:

‘This article comprises two articles I wrote seven years ago for Drink and Drugs News (DDN) in the UK – with a few small changes and additions (including headings).

The original two articles focused on the writing of William L. White and colleagues in the US. I thought it was interesting to look back and see what I was writing at that time.

1. Problems with our treatment system
“Something got lost on our way to becoming professionals – maybe our heart. I feel like I’m working in a system today that cares more about a progress note signed by the right color of ink than whether my clients are really making progress toward recovery.

I feel like too many treatment organizations have become people and paper processing systems rather than places where people transform their lives. Too much of our time is spent fighting for another day or a couple of extra sessions for our clients. I’m drowning in paper.

We’re forgetting what this whole thing is about. It’s not about days or sessions or about this form or that form, and it’s not about dollars; it’s about RECOVERY!”

A practitioner leaving the treatment field, quoted in Linking Addiction Treatment & Communities of Recovery: A Primer for Addiction Counselors and Recovery Coaches by William White and Ernest Kurtz

I have taken this quote from an excellent American article because it reminds me what working in this field is, or should be, about. No, not paperwork – recovery! [Mind you, many UK treatment workers complain that paperwork is taking over their real job, and some leave].[1]

William White’s writing has excited me ever since I was introduced to his book ‘Slaying the Dragon’ that focused on the history of addiction treatment and recovery in America. He has also written a range of inspiring articles on recovery from addiction on the Faces & Voices of Recovery website.

One of the important points that White and his co-authors make is that in the field today we tend to be very problem-focused, rather than what we should be, solution-focused. We tend to focus on addiction, rather than on recovery from addiction.

For example, we know a great deal about addiction, but much less about recovery. We have scientific journals and educational courses focusing on addiction or substances, but nothing on recovery. And look at the HBO series done in conjunction with the National Institute of Drug Abuse (NIDA) and other partners in America. The major message was about addiction – “addiction is a disease” – rather than about recovery from addiction.

Worryingly, many workers in the UK treatment field do not know what recovery is, and what factors facilitate the path to recovery. Some workers actually believe it is treatment that makes a person better.

The article of William White’s that I refer to – and strongly recommend you read – focuses not only on recovery, but also on communities of recovery.

White defines recovery as: “the experience (a process and a sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) problems utilize internal and external resources to voluntarily resolve these problems, heal the wounds inflicted by AOD-related problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life.”

There are a multitude of different pathways to recovery, of which only some involve formal treatment. Those who seek professional treatment often have a high personal vulnerability (e.g., family history of substance use problems, young age of problematic use, trauma in earlier life), greater problem severity and complexity, weaker social supports, and less occupational opportunities and success.

Formal treatment is a time-limited, circumscribed experience or series of experiences that interacts with and hopefully enhances a self-change process on the road to recovery.

White emphasises that treatment outcomes are compromised by the lack of sustained recovery support services. The need for such services becomes greater as problem severity increases and recovery capital decreases. [Recovery capital is the quantity and quality of internal and external resources that a person can bring to bear on the initiation and maintenance of recovery].

Research in America has shown that only 50% of people who enter treatment actually complete, whilst over 50% who complete use or drink again within the first year (80% of these within 90 days of discharge).

White points out that the resolution of severe substance use disorders can span years (sometimes decades) and multiple treatment episodes before stable recovery maintenance is achieved. For many individuals, recovery sustainability is not achieved in the short span of time that treatment agencies are involved in their lives.

When treatment agencies discharge clients following a brief episode of services, they convey the illusion that continued recovery is self-sustainable without further professional support. However, research reveals that durability of recovery from addiction – the point at which risk of future lifetime relapse drops below 15% – is not reached until after four or more years of sustained remission.[2]

As White emphasises, these findings beg the need for models of sustained post-treatment check-ups and support comparable to the assertive post-treatment monitoring used in other chronic disorders, e.g., diabetes, heart disease, and cancer.[3]

While the effects of acute treatment erode with time, the influence of the post-treatment environment increases. He argues that, “this is the environment we must niche within and remain within if we are truly interested in long-term recovery.” Assertive linkage to communities of recovery – involving recovered and recovering people – and other recovery support services are key.

2. Recovery and the recovery paradigm
William White is author of one of the truly great books in this field, ‘Slaying the Dragon: The History of Addiction Treatment and Recovery in America’.

He points out that there have been three organising paradigms over the past 200 years to try and deal with the problems caused by drugs and alcohol in the US. Pathology, whether religiously or medically conceived, provided an organising framework from the late 18th century through to the era of alcohol prohibition. This paradigm fuelled a debate as to whether alcoholism was a sin or a sickness.

The pathology paradigm was replaced by the intervention model, which “buttresses multi-billion dollar industries aimed at preventing drug use, controlling drug supplies, punishing drug offenders, and treating those with severe AOD [drug and alcohol] problems.” It is assumed that investigations into the etiology and patterns of substance use problems and studies of the professional treatment of these problems will reveal the ultimate solution to these problems.

This model has generated significant new understandings that sparked calls to bridge the gap between research and practice in addiction treatment. However, White and Kurtz point out that there has also been a disillusionment with this model because of the intractability of substance use problems at a societal level, resulting in a shift in focus to a third paradigm, one which focuses on resilience and recovery.

The recovery paradigm proposes that solutions to severe substance use problems “have a long history and are currently manifested in the lives of millions of individuals and families and that the scientific study of these lived solutions could elucidate principles and practices that could further enhance recovery initiation and maintenance efforts.”

In the US, there have been calls to shift the design of addiction treatment from a model of acute biopsychosocial stabilisation to a model of sustained recovery management. Moreover, a new recovery advocacy movement has developed.

Now you might be thinking, “What has this got to do with the UK?” We’ve got our treatment system, we have a mantra “treatment works”, etc, etc. [Please remember, I wrote the original article seven years ago!]

However, it has been pointed out to me on a number of occasions that in the treatment field we tend to be 15 – 20 years behind the US, which means that this shift in paradigm will be coming. [And it arrived!] Moreover, we must note that the treatment system in the US was effectively dismantled in the 1990s.

We also need to sit back and reflect on the current paradigm being used in the UK – the intervention model – and how we are using it. We need to ask ourselves whether we are so wrapped up in the idea of “treatment” that we forget what we are really doing, or should be doing, for the majority of people who need help, i.e. help them find recovery.

Some people who attend treatment are not particularly interested in stopping using drugs or drinking in the long-term, or do not believe they are capable of doing so. They want some respite from the chaos and damage that their substance use is causing them. Support from street-based agencies can provide a welcome period of respite, whilst a methadone programme can be beneficial for people who have been using heroin.   

However, a very significant proportion of people who access treatment want much more. They want to resolve their substance use problems permanently and go on to lead meaningful and fulfilling lives free of the substances that have caused their problems. On the basis of the definition below, they want recovery.  

Recovery is the process through which severe alcohol and other drug problems are resolved in tandem with the development of improved physical, emotional, ontological (spirituality, life meaning), relational and occupational health. [My adaptation of definition from White and Kurtz, 2005]

Many of these clients have a variety of other life issues – some caused by the substance use problem, others which preceded it – which they need help from professionals in resolving.

But is there sufficient help for those people who want to find recovery? And, are we getting carried away by the concept of treatment – and treating the symptoms, not underlying problems – to the exclusion of not understanding recovery (the real end- point) and helping people achieve it?

The resolution of substance use problems, or recovery, is something that ultimately comes from within the person. Treatment is a time-limited, circumscribed experience or set of experiences that helps this self-change process. Treatment is a tool, albeit a valuable one for many people, not an end in it its own right.

For many individuals, recovery sustainability is not achieved in the short span of time that treatment agencies are involved in their lives. As we discuss in a later Briefing, we need something additional to help people to find recovery.

I finish with a story I’ve heard so many time: ‘Person wants to stop using heroin is put on a methadone programme. He later asks that his dose be gradually reduced so he can work towards being abstinent. He is told his dose cannot be reduced because he will relapse. Period.’

Where is the focus: on his recovery (and well-being) or on treatment?

[I continued my DDN Background Briefings with a series of other articles which I will add to this site in one form or other in the near future. However, I will shortly follow this present article with a newly written piece on Recovery Management.]

[1] UK treatment workers continued to complain about the paperwork (and its priority) for years after and still do so today. I’ve heard the same complaints from Australian treatment workers.

[2] The figures quoted today are five years for alcohol addiction and seven years for heroin addiction. Of course, these figures might be reduced as society improves the system of care for people with serious substance use problems.

[3] Whilst addiction can be considered a chronic condition, I believe it should not be likened too closely to heart disease and diabetes. People do not generally overcome these latter conditions – they manage them. However, some people do overcome addiction and it never enters their life again. They do not need to spend time managing their condition every day. At the same time, I emphasise that addiction cannot be considered an acute condition, which is the assumption made by using an acute care system, the system used by most of our treatment system.’