Recovery: Old Wine, Flavor of the Month or New Organizing Paradigm?

Abstract

Recovery is emerging as an influential but ill-defined organizing concept for addiction treatment ¹ and the larger field of behavioral health care. The reification of the concept of recovery is discounted by some as nothing new (“We're already recovery oriented.”), an ephemeral fad lacking substance and import (“This is old wine in a new wineskin.”), or as hopelessly impractical (“Nobody will pay for it.”). This essay uses historical analysis and treatment system performance data to argue that recovery is a revolutionary concept. Policymakers who are embracing this concept via the vision of a recovery-oriented system of care are, in spite of innumerable obstacles, radically altering the present design of addiction treatment.

¹ Treatment can be briefly and usefully defined as a planned, goal directed change process, which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types—which aren't also used with non-substance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Nonclinical support and help is part of a broad range of mutual aid process which is not unique to the substance use(r) intervention arena. Editor's note.

Keywords:

• recovery
• recovery capital
• sustained recovery
• recovery mutual aid
• recovery management
• chronic disease model

Notes

¹ Treatment can be briefly and usefully defined as a planned, goal directed change process, which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types—which aren't also used with non-substance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Nonclinical support and help is part of a broad range of mutual aid process which is not unique to the substance use(r) intervention arena. Editor's note.

² The Recovery Community Support Program is a grant program initiated by the Center for Substance Abuse Treatment in 1998. Its early focus was on funding more than 30 local community organizations across the United States to mobilize communities of recovery, advocate pro-recovery social policies, run anti-stigma campaigns, and offer needed recovery support services. In 2002, the program changed to the Recovery Community Services Program with a focus on the development of peer-based recovery support services.

³ The Access to Recovery (ATR) Program is the product of a 2003 Presidential initiative that is now administered by the Center for Substance Abuse Treatment. The ATR program provided vouchers to people seeking addiction treatment and/or recovery support services so that they could choose those services that best suited their needs and circumstances. More than $100 million a year in ATR funds are channeled through state and tribal organizations.

⁴ The role of historical trauma and colonization in the rise and maintenance of Native American alcohol consumption related problems has been explored in considerable depth by Coyhis and White (2006), Brave Heart and DeBruyn, 1998; Brave Heart, 2003; Duran and Duran, 1995; and Morgan, 1983. These sources document the role of alcohol in the economic, political, and sexual exploitation of Native Americans; the creation of “firewater myths” as an instrument of colonization; and the Native American religious and cultural revitalization movements through which Native Americans resisted and responded to alcohol consumption related problems. The later movements include the Prophet Movement among the Delaware, Shawnee, and Kickapoo; the Handsome Lake Movement, the Native American Temperance Movement, the Indian Shaker Church and the early Peyote Societies that evolved into the Native American Church.

⁵ This concept-term, in its variations, is inadvertently misleading in that addiction, whatever its definition and etiology, is not being treated. A heterogeneous group of people manifesting a range of substance use and nonuse related behaviors, adaptations, and lifestyles of various qualities and appropriateness, given their various roles and functions in a range of contexts, networks, and environments are/can be “engaged” in “treatment” given necessary internal and external conditions. Editor's note.

⁶ This concept (and its first-cousin, protective factors), often noted in the literature, is all-too-often used without adequately understanding and considering its dimensions (linear, nonlinear), its “demands,” the critical necessary conditions which are necessary for it to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether its underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith” or what. What is necessary—endogenously as well as exogenously—for a “risk” process to operate? This is necessary to clarify if the term is not to remain as yet another shibboleth in a field of many stereotypes. If we don't currently know, in a generalizable sense, it behooves us to state this. Editor's note.

⁷ Common treatment methods with little or no evidence of their effectiveness include lectures, educational films, general alcoholism counseling, and milieu therapy (Wilbourne and Miller, 2002); an example of potentially harmful interventions include confrontational counseling techniques (see White and Miller, 2007 for a review).

⁸ The reader is referred to a growing literature about “structural barriers” to effective treatment-intervention planning, implementation, and assessment. Less of a literature exists about “structural bridges” or “facilitators” Editor's note.

⁹ Examples of such fuzziness include questions of whether recovery includes an altered relationship with all psychoactive substances including tobacco, whether the recovery concept embraces problem resolution strategies other than abstinence, whether recovery encompasses medication assistance (e.g., methadone, naltrexone), whether recovery requires more than a resolution of alcohol and other drug use problems, and whether recovery is an all or none concept or whether it is something that could be achieved partially. See White, in press, for a detailed discussion of such questions.