White, W.L. (2012). Historical perspectives on recovery support. Briefing paper presented at the UCLA / Betty Ford Institute Annual Recovery Conference, Rancho Mirage, CA, February 21-23, 2012. Briefing Paper Betty Ford Institute/UCLA Annual Conference on Recovery Historical Perspectives on Addiction Recovery Support William White Support for the personal resolution of severe and persistent alcohol and other drug (AOD) problems in the United States has for most of the past two centuries been provided through three primary mechanisms: family, kinship, and informal social networks; peer-based recovery mutual aid societies; and professionally directed addiction treatment. Today, new recovery support systems are emerging that are without historical precedent and that will exert a profound influence on the future of addiction treatment and recovery in the United States and throughout the world. Even the most cursory discussion of these changes requires a new recovery-focused lexicon. Historical Context: In a recent paper prepared for a special issue of the Journal of Groups in Addiction and Recovery, White, Kelly, and Roth1 1) reviewed the historical evolution of addiction treatment and the growth and diversification of recovery mutual aid societies in the United States,2 2) documented the emergence of a new recovery advocacy movement3 and new recovery support institutions (e.g., national and local recovery community organizations, recovery community centers, recovery homes, recovery schools, recovery industries, recovery ministries, recovery cafes, etc.),4 3) 1 White, W., Kelly, J., & Roth, J. (in press). New addiction recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery. 2 Also see Humphreys, K. (2004). Circles of recovery: Self-help organizations for addictions. Cambridge: Cambridge University Press. 3 Also see White, W. L. (2006). Let’s go make some history: Chronicles of the new addiction recovery advocacy movement. Washington, D.C.: Johnson Institute and Faces and Voices of Recovery; White, W. L. (2007). The new recovery advocacy movement in America. Addiction, 102, 696-703. doi:10.1111/j.1360-0443.2007.01808.x 4 Also see Valentine, P. A., White, W. L., & Taylor, P. (2007). The recovery community organization: Toward a working definition and description. Posted at http://www.facesandvoicesofrecovery.org/pdf/valentine_white_taylor_2007.pdf; Molloy, J. P., & White, W. L. (2009). Oxford Houses: Support for recovery without relapse. Counselor, 11(2), 28-33; White, W. L., & Finch, A. (2006). The recovery school movement: Its history and future. Counselor, 7(2), 54-58; White, W. L., & Whiters, D. (2005). Faith-based recovery: Its historical roots. Counselor, 6(5), 58-62. 1 described how these new institutions are being nested within an increasingly well-defined culture of recovery (with its own history, values, language, literature, symbols, rituals, art, music, etc.) influenced by but now transcendings pre-existing and insular treatment and recovery mutual aid cultures, and 4) discussed the implications of these changes to the addiction treatment enterprise. This brief paper extends the discussion within that paper. Recovery as an Organizing Paradigm: In tandem with, or possibly as a result of, the above outlined changes, recovery is emerging as a new organizing paradigm within the alcohol and drug problems arena.5 This is evidenced by: 1) early criticisms that addiction treatment had become detached from the larger and more enduring process of addiction recovery;6 2) the reconceptualization of addiction as a chronic disorder;7 3) growing interest in the varieties, pathways, styles, stages, and degrees of long-term addiction recovery—both personal recovery and family recovery;8 4) explorations of the role of medication in recovery initiation and/or maintenance, e.g., medication-assisted recovery, recovery-oriented methadone maintenance;9 5) calls to extend addiction treatment from a model of acute biopsychosocial stabilization to a broader model of sustained recovery management (RM) and to wrap RM within larger recovery-oriented systems of care (ROSC);10 6) multiple efforts by policy, clinical, research, and recovery advocacy leaders to achieve consensus on a recovery definition and measurable benchmarks of recovery;11 7) federal, state, and local recovery-focused systems 5 El-Guebaly, N. (in press). The meanings of recovery from addiction: Evolution and promises. Journal of Addiction Medicine. doi:10.1097/ADM.0b013e31823ae540; White, W. L. (2005). Recovery: Its history and renaissance as an organizing construct concerning alcohol and other drug problems. Alcoholism Treatment Quarterly, 23(1), 3-15. doi:10.1300/J020v23n01_02 6 Elise, D. (1999). Recovering recovery. Journal of Ministry in Addiction And Recovery, 6(2), 11-23; Morgan, O. J. (1995). Extended length sobriety: The missing variable. Alcoholism Treatment Quarterly, 12(1), 59-71. doi:10.1300/J020v12n01_05 7 Dennis, M. L., & Scott, C. K. (2007). Managing addiction as a chronic condition. Addiction Science & Clinical Practice, 4(1), 45-55; Flaherty, M. (2006). Special report: A unified vision for the prevention and management of substance use disorders: Building resiliency, wellness and recovery—A shift from an acute care to a sustained care recovery management model. Pittsburgh: Institute for Research, Education and Training in Addictions; McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association 284(13), 1689-1695. 8 White, W., & Kurtz, E. (2006). The varieties of recovery experience. International Journal of Self Help and Self Care, 3(1-2), 21-61. 9 Institute for Research, Education and Training on Addictions (IRETA). (2010). Recovery-oriented methadone: Improving practice to enhance recovery (Report prepared for Southwest Behavioral Health Management, Inc.). Pittsburgh, PA: IRETA; White, W. L., & Torres, L. (2010). Recovery- oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center; White, W., Parrino, M., & Ginter, W. (2011). A dialogue on the psychopharmacology in behavioral healthcare: The acceptance of medication-assisted treatment in addictions. Commissioned briefing paper for SAMHSA’s A Dialogue on Psychopharmacology in Behavioral Healthcare meeting, October 11-12, 2011. Posted at www.williamwhitepaers.com 10 Kelly, J., & White, W. L. (2011). Addiction recovery management: Theory, science and practice. New York: Springer Science. 11 Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33, 221-228. doi:10.1016/j.jsat.2007.06.001; 2 transformation initiatives;12 8) efforts to define RM and ROSC practices for particular populations and cultural contexts;13 9) the rapid expansion of peer-based recovery support services,14 new service roles, e.g., recovery coaches,15 and new systems for recruiting, training, credentialing, and supervising recovery coaches; 10) growing interest in post-treatment monitoring and support, e.g., recovery checkups and other assertive or adaptive approaches to continuing care;16 11) calls for a recovery research agenda;17 and Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33, 243-256. doi:10.1016/j.jsat.2007.04.014; McLellan, A. T. (2010). What is recovery? Revisiting the Betty Ford Institute Consensus Panel definition. Journal of Substance Abuse Treatment, 38, 200-201. doi:10.1016/j.jsat.2009.11.002; SAMHSA (2009). Working definition of recovery. Excerpt from National Summit on Recovery Conference Report, 2005. Rockville, MD: Center for Substance Abuse Treatment. Posted at www.williamwhitepaers.com; United Kingdom Drug Policy Commission. (2008). A consensus definition of recovery. Retrieved June 24, 2010 from http://www.ukdpc.org.uk/resources/A%20Vision%20of%20Recovery.pdf; White, W. L. (2007b). Addiction recovery: Its definition and conceptual boundaries. Journal of Substance Abuse Treatment, 33, 229-241. doi:10.1016/j.jsat.2007.04.015 12 White, W. L. (2008). Perspectives on systems transformation: How visionary leaders are shifting addiction treatment toward a recovery-oriented system of care. (Interviews with H. Westley Clark, Thomas A. Kirk, Jr., Arthur C. Evans, Michael Boyle, Phillip Valentine and Lonnetta Albright). Chicago, IL: Great Lakes Addiction Technology Transfer Center. 13 Haberle, B., & White, W. (2007). Gender-specific recovery support services: The evolution of the Women’s Community Recovery Center. Posted at http://www.facesandvoicesofrecovery.org/pdf/White/white_haberle_2007.pdf.; White, W.L., Evans, A.C., Ali, S., Abrahams, I., & King, J. (2009). The recovery revolution: Will it include children and adolescents? Philadelphia: Department of Behavioral Health and Mental Retardation Services; White, W. L., & Sanders, M. (2008). Recovery management and people of color: Redesigning addiction treatment for historically disempowered communities. Alcoholism Treatment Quarterly, 26(3), 365- 395. doi:10.1080/07347320802072198 14 White, W. L. (2009). Peer-based addiction recovery support: History, theory, practice, and scientific evaluation. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services. 15 Loveland, D., & Boyle, M. (2005). Manual for recovery coaching and personal recovery plan development. Posted at http://www.bhrm.org/guidelines/addguidelines.htm; White, W. L. (2004). Recovery coaching: A lost function of addiction counseling? Counselor, 5(6), 20-22; White, W. (2006). Sponsor, recovery coach, addiction counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health. 16 Dennis. M. L., Scott, C. K., & Funk, R. (2003). An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning, 26(3), 339-352. doi:10.1016/S0149-7189(03)00037-5; Dennis M. L., & Scott, C. K. (in press). Four- year outcomes from the Early Re-Intervention (ERI) experiment using Recovery Management Checkups (RMCs). Drug and Alcohol Dependence. doi:10.1016/j.drugalcdep.2011.07.026; Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., & Passetti, L. L. (2007). The effect of assertive continuing care on continuing care linkage, adherence, and abstinence following residential treatment for adolescent substance use disorders. Addiction, 102, 81-93. doi:10.1111/j.1360-0443.2006.01648.x.; McKay, J. R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100(11), 1594-1610. doi:10.1111/j.1360-0443.2005.01208.x 17 Laudet, A., Flaherty, M., & Langer, D. (2009). Building the science of recovery. Pittsburgh, PA: Institute for Research, Education and Training and Northeast Addiction Technology Transfer Center. Laudet, AB. (2008). The road to recovery: Where are we going and how do we get there? Empirically driven conclusions and future directions for service development and research. Substance Use & Misuse, 43, 2001-2020. doi:10.1080/10826080802293459; White, W., & Chaney, R. (in press). Commentary--Resilience and recovery across the generations: A critical research agenda. Counselor; 3 12) recovery prevalence surveys and recovery resource mapping projects. It remains to be seen whether recovery will be a viable and sustained or ephemeral organizing concept for the AOD problems arena.18 The Ecology of Resilience and Recovery: One of the by-products of this evolution in thinking and practice is growing interest in what might be called the ecology of resilience and recovery—the multi-directional influences exerted by person, family, neighborhood, workplace, school, church, community, and culture on AOD problem resilience, resistance, and recovery.19 This interest includes a heightened focus on how these contextual influences interact with personal/family vulnerabilities to perpetuate or break intergenerational cycles of addiction and related problems. Future breakthroughs in addiction treatment and recovery support may well lie in the integration of neurobiological and psychological understandings of addiction and recovery with broader frameworks that focus on environmental (physical, social, and cultural) factors. Key Propositions: The trends outlined by White, Kelly, and Roth rest on several propositions that are explicitly outlined below. 1. Addiction recovery often involves a journey between two physical and cultural worlds—passage from a culture of addiction to a culture of recovery.20 The weight of personal and historical baggage can delay and impede this journey, particularly where alcohol and other drugs have been used as tools of colonization and oppression.21 2. The physical, emotional, and cultural passage from addiction to recovery can be aided by exposure to wounded healers22—persons who have survived and White, W., & Godley, S. (2007). Adolescent recovery: What we need to know. Student Assistance Journal, 19(2), 20-25. 18 White, W. L. (2008). Recovery: Old wine, flavor of the month or new organizing paradigm? Substance Use and Misuse, 43(12&13), 1987-2000. doi:10.1080/10826080802297518 19 White, W. L. (2009). The mobilization of community resources to support long-term addiction recovery. Journal of Substance Abuse Treatment, 36, 146-158. doi:10.1016/j.jsat.2008.10.006 20 White, W. L. (1996). Pathways from the culture of addiction to the culture of recovery. Center City, MN: Hazelden. 21 See Coyhis, D., & White, W. (2006). Alcohol problems in Native America: The untold story of resistance and recovery-The truth about the lie. Colorado Springs, CO: White Bison, Inc.; White, W., & Sanders, M. (2002). Addiction and recovery among African Americans before 1900. Counselor, 3(6), 64-66; O’Connor, G. (ND). Recognizing and healing malignant shame. Retrieved March 3, 2012 from http://www.zonezero.com/magazine/essays/distant/zreco2.html 22 Borkman, T. (1976). Experiential knowledge: A new concept for the analysis of self-help groups. Social Service Review, 50, 443-456; Jackson, S. W. (2001). The wounded healer. Bulletin of the History of Medicine, 75, 1-36; McKnight, J. (1995). The careless society: Community and its counterfeits. New York: Basic Books; Ungar, M., Manuel, S., Mealey, S., Thomas, G., & Campbell, C. (2004). A study of community guides: Lessons for professionals practicing with and in communities. Social Work, 49(4), 550-561. doi:10.1093/sw/49.4.550; White, W. L. (2000). The history of recovered people as wounded healers: I. From Native America to the rise of the modern alcoholism movement. Alcoholism Treatment Quarterly, 18(1), 1-23. doi:10.1300/J020v18n01_01; White, W. L. (2000). The history of recovered people as wounded healers: II. The era of 4 extracted lessons from their own personal/family recovery experience—and by assertive linkage to one or more communities of shared recovery experience. 3. Recovery is contagious. Like addiction, recovery is often transmitted interpersonally, but, in contrast to addiction, is transmitted by affection rather than infection.23 Many people catch recovery before they choose it.24 4. Recovery prevalence in a neighborhood, social institution (e.g., school or workplace), community, or culture is influenced by the density of recovery carriers—persons in recovery who are committed to carrying a message of hope to those individuals and families still experiencing AOD problems. 5. Carrying the recovery message interpersonally is as beneficial to the recovery carrier as to the recipients of such messages25 through what Frank Riessman christened the helper principle.26 6. Recovery prevalence (the proportion of people with lifetime AOD problems who have resolved those problems) and the density of recovery carriers (the number of people in recovery active in service work within a community at any point in time) constitute crucial elements of community recovery capital—resources within a local community that can be identified and mobilized to help individuals and families initiate and sustain addiction recovery.27 7. Long-term recovery outcomes related to participation in addiction treatment, a recovery mutual aid society, and/or other forms of peer recovery support may hinge as much on the existence, accessibility, scope, and depth of community recovery capital as it does intrapersonal or interpersonal factors within the family.28 professionalization and specialization. Alcoholism Treatment Quarterly. 18(2), 1-25. doi:10.1300/J020v18n02_01 23 A distinction first brought to my attention by Kathy Griffin. 24 White, W. L. (2010). Recovery is contagious. Posted at www.facesandvoicesofrecovery.org and www.williamwhitepapers.com 25 Pagano, M. E., Friend, K. B., Tonigan, J. S., & Stout, R. L. (2004). Helping others in Alcoholics Anonymous and drinking outcomes: Findings from Project MATCH. Journal of Studies on Alcohol, 65, 766-773; Zemore, S. E., Kaskutas, L. E., & Ammon, L. N. (2004). In 12-Step groups, helping helps the helper. Addiction, 99, 1015-1023. doi:10.1111/j.1360-0443.2004.00782.x; Witbrodt, J., Kaskutas, L, Bond, J., & Delucchi, K. (2012). Does sponsorship improve outcomes above Alcoholics Anonymous attendance? A latent class growth curve analysis. Addiction, 107, 301-311. doi:10.1111/j.1360-0443.2011.03570.x 26 Riessman, F. (1965). The “helper” therapy principle. Social Work, April, pp. 27-32. 27 White, W. L. (2011). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific studies, 1868-2011. Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center; White, W. L., & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27. 28 Humphreys, K., Moos, R. J., & Cohen, C. (1997). Social and community resources and long-term recovery from treated and untreated alcoholism. Journal of Studies on Alcohol, 58(3), 231-238; Moos, 5 8. The density of recovery carriers within a local community can be strategically increased through such activities as hosting regular recovery celebration events, honoring local recovery carriers, training recovery advocates and recovery coaches, and offering storytelling training to all persons in recovery.29 9. Community recovery capital can be strategically increased by nurturing the development of secular, spiritual, and religious recovery mutual aid options, recovery support groups for special populations/needs, peer recovery support service projects, and by supporting recovery advocacy activities that create a community climate (beliefs, attitudes, policies, recovery visibility) in which recovery can flourish.30 10. The strategic expansion of recovery support institutions and the development of vibrant local recovery cultures could result in several important outcomes:  Increased rates of natural recovery—the number of people, particularly those with lower AOD problem severity and complexity, initiating and sustaining recovery without participation in addiction treatment.  Increased retention and recovery rates within addiction treatment and recovery mutual aid organizations, particularly among those individuals who present with high problem severity/complexity/chronicity and low recovery capital.  The discovery of particularly potent combinations and sequences of professional and peer supports capable of generating long-term recovery outcomes better than could be achieved through any of these elements used in isolation, e.g., the biopsychosocial equivalent of the AIDS “cocktail” or combined surgery and chemotherapy for cancer.  The discovery of particular service/support combinations/sequences that work best with key populations, e.g., women, adolescents, people with co-occurring disorders, people re-entering the community from prison, etc.31 11. The emergence of a new recovery advocacy movement, new recovery institutions, and a flourishing national culture of recovery is stirring interest in the concept of community recovery—the idea that there are neighborhoods or whole communities wounded by AOD and related problems to the extent that they may R. H., & Moos. B. S. (2007). Protective resources and long-term recovery from alcohol use disorders. Drug and Alcohol Dependence, 86, 46-54. doi:10.1016/j.drugalcdep.2006.04.015 29 White, W. L. (2009). The mobilization of community resources to support long-term addiction recovery. Journal of Substance Abuse Treatment, 36, 146-158. doi:10.1016/j.jsat.2008.10.006 30 Ibid. 31 White, W., Kelly, J., & Roth, J. (in press). New addiction recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery. 6 require their own community-level recovery process—what the Native American Wellbriety Movement has cast as a Healing Forest.32 12. Particularly promising are strategies that integrate personal, family, and community intervention strategies over a prolonged period of time via the increased integration of prevention, early intervention, treatment, recovery support, and health and wellness initiatives. This will entail bridging clinical models of intervention with environmentally focused public health models. For addiction treatment providers, this will involve blending traditional (intrapersonal) strategies of clinical intervention with broader recovery-focused community development and cultural revitalization strategies. Summary The history of help to resolve severe AOD problems has evolved through six overlapping areas of development: 1) failing to adequately address severe, complex, and often chronic AOD problems in non-specialty service settings (a continuing theme), 2) creating specialty-sector addiction treatment resources to facilitate recovery initiation (biopsychsocial stabilization) within an institutional environment, 3) extending acute treatment services into the community (via community-based outpatient care and early intervention efforts in medicine, business and industry, education, and allied health and human services), 4) achieving recovery maintenance through closed addiction recovery mutual aid societies, 5) extending acute care models of addiction treatment toward models of sustained recovery management (currently under way), and 6) an emerging era of mobilizing recovery communities to create the physical, psychological, social, and cultural space in which personal/family life in long- term recovery can flourish and to help heal larger wounded systems (e.g., families, neighborhoods, communities). This history reflects discrete areas of focused attention: buttressing the will to recover, codifying the means of maintaining recovery, enhancing the quality of personal/family life in long-term recovery, and creating a healthy community milieu within which AOD problems can be prevented and long-term addiction recovery can be firmly nested. Calls for professional models of sustained recovery management and the creation of recovery-oriented systems of care seek, in their essence, to link and fully integrate these historical developments. That achievement would exert a potentially profound influence on the future of addiction treatment and recovery and the global health of families, communities, and societies. 32 Coyhis, D., & White, W. (2006). Alcohol problems in Native America: The untold story of resistance and recovery-The truth about the lie. Colorado Springs, CO: White Bison, Inc.; The Red Road to Wellbriety. (2002). Colorado Springs, CO: White Bison, Inc. 7 8