Recovery and Straw Men: An Analysis of the Objections Raised to the Transition to a Recovery Model in UK Addiction Services

Abstract

In both Scotland and England, the current drug strategies (HM Government, 2008; Scottish Government, 2008) have demonstrated a clear commitment to an integrated recovery-oriented model of treatment for drug problems, which represents a significant change in focus toward a more person-centered and individualized philosophy for the delivery of drug treatment in the United Kingdom. This change has met with some resistance from a range of professionals in the United Kingdom, and the purpose of the article is to make explicit these concerns and objections, classify them, and examine their foundations. A group of UK academics, policymakers, and practitioners, who met under the auspices of the UK Recovery Academy, agreed to collate a list of objections to the viability of recovery approaches in the addiction field and to assess the merits of each concern. This process resulted in a total of 26 objections that are reviewed. The article concludes with an overview of the questions remaining unanswered in the United Kingdom and an assessment of the position of the “recovery movement” in the UK addictions field.

KEYWORDS:

• recovery
• treatment effectiveness
• harm reduction

INTRODUCTION

There has been a fundamental shift in policy in both Scotland and England toward a recovery perspective. This follows a strategy (Home Office, 1998), particularly in England for illicit drug users, that targeted reducing the harms from drug-related offending and disease dissemination that was predicated on targets of increasing the numbers in “structured” (primarily statutory social care and health) treatment services (National Treatment Agency for Substance Misuse [NTA], 2002). This was largely based on a system designed to reduce harms involving long-term prescribing delivered though specialist treatment services. The 2008 drug strategy for England (HM Government, 2008) has a foreword from the then-home secretary stating, “Our aim is that fewer and fewer people start using drugs; that those who do use drugs not only enter treatment but complete it and re-establish their lives” (HM Government, p. 4).

The UK government strategy (HM Government, 2008) also asserts that “on treatment: use all emerging and all available evidence to make sure we are supporting the treatment that is most effective, targeted on the right users—with abstinence-based treatment for some, drug-replacement over time for others and innovative treatments including injectable heroin and methadone where they have been proved to work and reduce crime” (HM Government, p. 6). This generates a challenge for service commissioners and providers as the document aims to provide a “new focus on re-integration, providing the right level of support for people with drug problems to move towards treatment, training and employment” (HM Government, p. 11). The challenge of reconciling this switch in focus with an evidence base that is strongly supportive of a pluralistic approach to treatment interventions is a significant challenge.

In Scotland, the aim is even more explicit. The executive summary, “The Road to Recovery” (Scottish Government, 2008), states, “Central to the strategy is a new approach to tackling problem drug use based firmly on the concept of recovery. Recovery is a process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society” (Scottish Government, p. vi). The report goes on to assert that the explicit purpose of all treatment services is recovery—which in turn is characterized as an “aspirational, person-[centered] process” (Scottish Government, p. 23).

So where has this impetus for recovery come from? In international terms, there are two primary sources: The first is the work of the Betty Ford Institute Consensus Panel (2007) defining recovery as “a voluntarily maintained lifestyle [characterized] by sobriety, personal health and citizenship” (p. 222). The paper goes on to differentiate stages of recovery, classed as “early sobriety” (the 1st year), “sustained sobriety” of between 1 and 5 years, and “stable sobriety” of more than 5 years. The second source is the work of William White, who in the monograph, Peer-Based Addiction Recovery Support, describes recovery as consisting of three elements: “sobriety (abstinence from alcohol, tobacco, and unprescribed drugs), improvement in global health (physical, emotional, relational and ontological—life meaning and purpose), and citizenship (positive participation in and contribution to communal life)” (2009a, p. 16).

Additionally, the growth and perceived success of a service user-driven movement for mental health both in the United Kingdom and internationally, as well as the growth and diversification of mutual aid groups, ¹ supported by an increasingly compelling body of evidence about their effectiveness (Humphreys, 2004) ² , has led policymakers at a local and national level to assess the recovery activity in local communities that is rich and diverse and that is progressing irrespective of funding support or research endorsement. This has also prompted funded pilots of “recovery-focused” projects such as the Lothian and Edinburgh Abstinence Project (LEAP) in Edinburgh and Burton Addiction Center in Staffordshire that have yielded extremely encouraging early evaluations (Best, Loaring, Anane, & Morrell, 2009; Clark & Davies, 2005; Figure 8, 2008). Both of these projects would now be regarded as part of the mainstream of service provision.

Following on from the Betty Ford definition, the UK Drug Policy Commission (UKDPC) convened a meeting of senior UK practitioners and academics to develop a UK “vision” of recovery characterized as “voluntarily sustained control over substance use which maximizes health and [well-being] and participation in the rights, roles and responsibilities of society” (UKDPC Consensus Group, 2007, p. 6). The report emphasizes the range of routes to recovery and also suggests that this includes “medically maintained abstinence” (UKDPC Consensus Group, 2007, p. 6). In spite of this apparent flurry of recovery-directed policy activity, services are currently primarily measured on getting and keeping numbers in substitution treatment. The move to a Recovery Agenda affords policymakers an opportunity to change to recovery-oriented measures of service performance such as gains in recovery capital, but there is a concern that the resources, milestones, and structures may not be in place to enable such change or indeed to provide a framework for evaluating whether it has been adequately implemented.

In England, the Home Office has estimated that there were 327,466 problem drug users in treatment in 2005 (Singleton, Murray, & Tinsley, 2008) of whom an estimated 281,320 were opiate users and 192,999 were crack cocaine users, suggesting that poly-drug opiate use is the prime pattern of use in this group. The Home Office defines “problem drug use” as “persons using heroin, methadone, other opiate drugs or crack cocaine” (Singleton et al., p. 3). In 2008, the NTA for England estimated that there were 202,666 individuals engaged in structured drug treatment in England in 2007–2008. This represents 61.9% of the most recent Problem Drug User (PDU) estimate, yet only 35,441 (17.5%) were reported as successfully completing treatment. Although there is some evidence that this has resulted in more effective delivery of treatment to substance-using offenders and so has led to crime reduction (Skodbo et al., 2007), the evidence of impact on drug-related mortality and dissemination of blood-borne viruses is much weaker (Health Protection Agency, 2008; St. Georges Hospital, 2008).

This high rate of treatment engagement is in part due to the delivery of health care in the United Kingdom, with the majority of this provision accessed through the National Health Service (NHS) and so free at the point of delivery. It may also reflect national targets that have focused on decreases in waiting times for treatment and an improvement in engagement strategies, without matched commitments to measuring or supporting long-term recovery or behavior change. In essence what this has meant—for England in particular—is a system that has made access to treatment very easy for drug users, but planned exits from treatment are not as well measured nor managed within services. Furthermore, this has meant that treatment is generally provided within a clinical framework of assessment and structured interventions, and so engagement with community groups or mutual aid (AA, NA, peer after-care groups) would not be included in the measurement of treatment delivery or in the commissioning of local treatment systems. What is paid for and what is counted is the delivery of “structured” (as defined in the NTA's Models of Care [2002; updated, 2006]), and the role of community and peer activity is generally not included within formal measurement models.

In turn, this has meant that two separate therapeutic approaches have developed in statutory care (delivered through health and social services and large third sector “charities”) and mutual aid groups, with little linkage between the two and some suspicion on the part of many professionals about the nature of 12-step and other community-based approaches (Best et al., in press; Day, Gaston, Furlong, Murali, & Coppello, 2005). While good services would recognize the importance of linking to community groups such as AA and NA, the evidence would suggest assertive linkage is necessary to maximize these gains (Timko, deBenedetti, & Billow, 2006), and good services are also those where staff and management are aware of and have a stake in what is happening in their local community. A further challenge is for statutory care and mutual aid groups to link in with local communities to support social inclusion and recovery. It has been argued that treatment in the United Kingdom basically means “a bucket and straw, and a chat with a harassed drugworker” (Best, Groshkova, & McTague, 2009, p. 15) with little indication of how people might actually be supported to initiate a recovery journey. However, this does not reflect the individuals and services that strive to deliver much more than this and may become future “recovery champions.” This belief is being addressed, to some extent, with national competency standards set for workers in the drug and alcohol field: the Drugs and Alcohol National Occupational Standards (DANOS; HM Government, 2008).

Rationale

The UK Recovery Academy was founded in July 2009 with the aim of identifying recovery activities in UK communities, developing an evidence base for recovery-focused work, and promoting recovery as part of an agenda of improving engagement, choice, and hope for substance users. It is a collection of academics, practitioners, and policymakers who have been inspired by the successes of the recovery movement in the United States (evidenced by the work of William White [2008] and Faces and Voices of Recovery) and the achievements of the recovery movement in mental health in the United Kingdom (as summarized in Slade, 2009). The aim was to collate information about recovery activities in the addictions field in the United Kingdom, to identify and disseminate research, and to promote the collection of evidence about recovery activities, supporting and sharing the work of those involved in attempting to generate an evidence base in this area.

At the initial meeting, held in Manchester, around 80 people gathered during 2 days to discuss the role for the Recovery Academy, and a considerable proportion of the time was devoted to identifying the barriers to implementing recovery-oriented systems of care (White, 2007) and promoting recovery in the United Kingdom. The aim of this article is to understand these concerns and objections, and in the process of working through these, to develop a deeper and more collaborative understanding between all members of the treatment system. The success of the recovery movement has been based on hope and dynamism, and it was our intention to identify and address these barriers where possible and where the concerns are more fundamental to identify the tasks and challenges that lay ahead.

Given that both strategies, particularly the Scottish strategy, overtly state that the purpose of all treatment services is recovery oriented, one of the key aims of the article is to examine the perceived barriers to the implementation of this policy and how good the evidence is for possible objections that may be raised. While there is a strong evidence base for the effectiveness of treatment approaches (Gossop, Marsden, & Stewart, 2003; Prendergast, 2007; Simpson & Sells, 1990), the challenge is to assess how these can constitute the basis for a model that focuses on broader aspects of recovery such as quality of life, family functioning, and active contribution to communities and to the wider society.

Method

The initial discussions were recorded from the meeting, and an initial list of negative perceptions and concerns about both the principles of recovery and their application in a UK context were constructed. These were structured into clusters and circulated to members of the Recovery Academy with the request that they were discussed in wider groups to attempt to develop a comprehensive list. Outlined below are broad areas of concerns, specific comments or objections, and some initial attempt to address these concerns. In other words, there were three phases:

1. Generation of an initial list of concerns from attendees at the initial meeting.

2. Synthesis of these concerns into coherent themes.

3. Circulation of this list to interested individuals to collate responses and perceptions of the viability of these concerns.

In the discussion below, each “cluster” of areas for concern has been listed with a preliminary attempt at addressing them.

RESULTS

In this first section, the concerns are primarily about the transition to abstinence. Recovery does not only include an abstinence orientation, but in practice, for many people this is what recovery will mean. The section below examines some of the concerns about abstinence-oriented aspects of recovery.

Ashton's (2007) “New Abstentionists” article looked at the evidence supporting the use of methadone substitution and points out that social reintegration does not require abstinence from prescribed medication. Ashton acknowledges that the English National Treatment Outcome Research Study (NTORS; Gossop, Marsden, & Stewart, 2001, Gossop et al., 2003) improvement in psychological health and other drug use was disappointing. In line with the Recovery Agenda, he acknowledges the difficulty in consistently accessing holistic individualized care plans, particularly around housing, employment, and training.

A. Risk and Governance—Recovery Is Not Safe

1. There Are No Viable and Safe Alternatives to Prescribing

There is good evidence supporting prescribing interventions that are detailed in the National Institute for Health and Clinical Excellence (NICE; 2008) guidelines on the use of methadone and buprenorphine for the management of opioid dependence. Dolan, Wodak, and Hall (1998) also noted that methadone reduced the risk of injecting and this reduced viral transmission, which is a significant risk of increased mortality among drug users, while abstinence-orientated treatment has been associated with accidental overdose (Strang et al., 2003). Rates of accidental overdose may be reduced in a recovery-orientated system where more intensive support could be available in the form of “recovery checkups” (Dennis, Foss, & Scott, 2008). A recovery-centered system could work alongside the individual to offer both maintenance and abstinence-based treatments based on an informed-consent person-centered process. It was felt that system change could reduce even if it could not remove the increased risk associated with abstinence-oriented treatments. Additionally, abstinence and recovery are not synonymous—and much medication-assisted recovery would be possible without achieving abstinence.

2. We Are Only Following the Evidence-Based Guidelines From NICE; the Only Evidence-Based Treatments Are Maintenance Based

The 2007 NICE guidance stated that “some dependent people may make dramatic changes in their drug use without formal treatment.” The evidence base in recovery is very limited and would not meet the standards of NICE or Cochrane Reviews. This is an area that needs to be addressed, developing new methodologies and evaluating the effectiveness of recovery-orientated systems of care. However, the NICE principles are based on a narrow view of science based on accumulated evidence that is much weaker around detoxification and around long-term rehabilitation of drug users.

3. Once a Client Is Effectively Maintained, Encouraging Change Is to Risk Relapse, Overdose, and Death

This is in effect an extension of the safety point above. Recovery involves a commitment to a move toward health, strengths, and wellness. It has hope and aspiration as core features, with self-management encouraged and facilitated (Slade, 2009). The clinician moves from being “the expert” to a coaching role, working alongside the client. Opportunities for choice, however small, may enable people to recover an “internal locus of control” (Deegan, 1996). The functioning client becomes in charge of decision making and acknowledges that they may or may not succeed in their attempt at abstinence but that the right to choose their path and make their mistakes is their own.

There is understandable concern about the exceptionally high rate of postdetoxification deaths (Strang et al., 2003). Currently, there is generally little support in place for clients who are newly abstinent. Increased requests for detoxification would need to have more intensive support available. The nature of this support is open to debate (Best, O’Grady, Charalampous, & Gordon, 2005; NTA, 2002). The increased mortality risk associated with interventions other than maintenance (or no intervention; e.g., Warner-Smith, Darke, Lynskey, & Hall, 2001) is one of a range of risk factors that clients must be made aware of if they wish to choose abstinence-oriented recovery. However, there is also a system responsibility to improve the treatment supports (such as recovery management checkups and ready access to relapse support) and to bolster the community supports (including access to after-care and peer and mutual aid groups) that will reduce the risks to the person seeking this form of recovery.

There is also an interesting epidemiological issue that has recently arisen in England: Even with unprecedented levels of treatment “penetration” as outlined above (NTA, 2009), which suggest that around 65% of problem drug users in England are in contact with treatment services, this has coincided with increased numbers of deaths. St. Georges Hospital (2008) reported an 8.4% increase in drug-related deaths from 2006 to 2007 in the United Kingdom, suggesting that improved access to treatment has not, at a population level, done enough alone to reduce the rate of drug-related deaths. Additionally, acute overdose-related deaths as measured in the official UK drug deaths statistics (St. Georges Hospital) do not take into account the chronic deaths not only from blood-borne virus but also from lung and liver damage, nor the reduced quality of life that has frequently been linked to long-term methadone prescribing (Best et al., 1998; Loth, Schippers, Hart, & van de Wingaart, 2007). Finally, there is no inconsistency between recovery and harm reduction approaches: One of the main “recovery” services in Scotland (LEAP) has been at the forefront of introducing naloxone and intensive overdose training in Scotland.

4. Addiction Is a Chronic Relapsing Condition—We Would Not Ask Diabetics to Stop Their Insulin at a Certain Point, So Why Should We Do It With Addicts?

Definitions of recovery are inclusive of maintained recovery. Although for many the course of addiction is chronic and relapsing, this is not always the case. The difficulty is that although we know the statistics for a population, this translates poorly into predicting the outcome for an individual client. This would not be the case for a patient with insulin-dependent diabetes where we know the life-threatening sequelae of stopping their insulin injections. Most physical and mental health conditions are not so clear cut in nature (e.g., autoimmune disease or depression). In these conditions, the course is often unpredictable.

The patient has to balance information about their condition against the side effects/restrictions of the medications prescribed. This seems more analogous to a client in maintained recovery, where relapse and overdose are real risks, but should be weighed against the person's needs and their “recovery capital” (White & Cloud, 2008). What this would suggest is that the extent of such risks is mediated by the resources available to the client and that not all of those who attempt an abstinence-oriented recovery will be at equal risk nor should there be the assumption that interventions (including treatment) cannot build protective strength in the form of peer, family, and community supports and the personal skills and resources to prevent harmful outcomes and indefinite chronicity. Additionally, while type 1 diabetes is largely about insulin deficiency, very few people would suggest that heroin addiction is about opiate deficiency.

5. How Do We Account for Things Like the Safeguarding of Children and Vulnerable Adults in a Recovery Model?

Safeguarding children and young people is everyone's responsibility (http://www.swcpp.org.uk), with the needs of the child having primacy. People in statutory, voluntary, and independent organizations who work with children or their carers should be trained together as equals, and this should reduce the risks outside the more structured services. The value of people working together, communicating with each other, and sharing information in ways that protect children from harm is promoted. Best Practice in Managing Risk from the Department of Health (2007) looks at balancing care needs against risk needs that emphasize positive risk management, a collaborative approach with everyone involved in the client's care, and the importance of recognizing and building on client's strengths as would be considered in a recovery model. As Slade (2009) has argued, in relation to mental health recovery, the key is “distinguishing between harmful risks and positive risk-taking, having [organizationally] endorsed approaches to setting treatment goals to [minimize] harmful risks and recovery goals to [maximize] risk self-management, valuing the dignity of risk and giving primacy as much as possible to recovery goals over treatment goals” (p. 213).

There is, however, a more complex challenge around effectiveness of safety management and governance as clients move from more structured to more community-driven services, and it will be essential that recovery-oriented models of care incorporate adequate support systems and partnership, working to ensure that the safety of individuals in recovery and their families are adequately protected.

Naturally, the application of risk and governance will be different in less structured environments, not only involving mutual aid but also outreach, community work, and needle exchange services, where assessment and case management will be markedly less formal. Mutual aid organizations could be encouraged to have basic awareness training to develop competencies around safeguarding children and vulnerable adults to the extent that this does not conflict with their basic principles of personal responsibility. As the level of contact is increased in a recovery model, with clear policies and training in place, families may receive greater support with a potential to reduce risks. Services may feel empowered by seeing other services safely adopt this model with subsequent dissemination of good practice and policies. Awareness and information sharing are essential in developing recovery-oriented systems of care.

Linked to this is that there is a powerful and well-established evidence base for methadone maintenance treatment (Department of Health & Combined Administrations, 2006; NICE, 2007), but there is no equivalent for recovery. White (2007, 2008) has demonstrated that sustained recovery is achievable—not only through participation in rehabilitation programs but also without engagement in formal treatment interventions. The latter—often referred to as “natural recovery” (Granfield & Cloud, 2001)—has been poorly evidenced in the United Kingdom, and there remains a paucity of evidence about abstinence-oriented treatments in the United Kingdom and of cohort studies that would attempt to address long-term change, akin to the work done in the United States by Dennis and colleagues (2008).

B. The Preservation of the Status Quo and the Lack of a Viable Alternative

6. Lots of Maintained Clients Are Doing Really Well—Some Have Jobs and Are Doing Courses

Maintained recovery is a valid personal choice, and many people have fulfilling lives on prescriptions. The Alliance (formerly Methadone Alliance) advocates a balanced assessment of treatment possibilities with the belief that clients need a real voice in their treatment. However, little data exist to examine the recovery capital of clients in maintained treatment. Ginter (White, 2009b) has argued that maintained recovery is possible but that the systems and structures of treatment make the development of recovery communities difficult to achieve in maintenance clinics and that the culture has not encouraged the development of peer support networks.

7. We Already Provide Recovery Services—We Have Pathways to Training and Housing and Mental Health Services

Most clinicians would view themselves as helping clients move on. The question becomes whether what we offer could be improved. Assertive engagement is rarely used in drug services, and sometimes pathways between services are not easy to navigate. The aspirations and hopes of some treatment service staff may need augmenting for this to translate to their clients. Recovery champions and managers may have a role to play in this. However, again, we have little evidence to support an assertion that we work in a recovery model currently. And in the United Kingdom, at a time of limited resource, it is difficult to prioritize the more time-consuming and demanding aspects of treatment packages while targets do not focus on these issues and commissioning has largely eschewed the performance management of recovery in the United Kingdom.

8. AA and NA Are Just Religious Cults in Disguise—It Is Brainwashing

The concerns about AA/NA tend to focus on three primary issues: the perceived lack of an evidence base, the perception that it is “merely a substitute addiction,” and that it is religious or a cult. Humphreys (2004) has documented a very strong evidence base supporting AA in particular but also other forms of mutual aid, while the other perceptions are reflective of an increasingly secular UK society and the tensions between the rationalist model of drug treatment delivery and what is seen to be about lifestyle and commitment. The low levels of interaction between mutual aid groups and formal treatment providers have supplemented this stereotyping and negative perception and may have acted as a barrier to engagement for some clients (Best et al., in press). A key challenge in this arena is to challenge the perceptions of clients and workers and to improve the linkage and engagement between services and local community groups (e.g., Timko et al., 2006).

9. Staff in Agencies Outside the Health Service Are Not Well Trained Enough, and I Don't Trust Them with My Clients

It is understandable that staff may have concerns about staff in other agencies, and these concerns may be founded in ignorance or reality. Closer links between agencies, particularly with joint training and common policies, can address some of these concerns. The implementation of these changes in working practice needs careful thought to overcome these barriers and cultural differences. White (2007) has argued that involving community group members in training of staff is an important step forward as is requiring staff in structured services to spend some time in community and mutual aid groups as part of their professional development.

In the United Kingdom, partnership commissioning means that there is often centralized coordination of service provision, and local commissioners may well have a vital role to play in addressing this kind of concern.

The Treatment Process Model (Simpson & Flynn, 2007) makes very clear the link between worker motivation and engagement, the development of a therapeutic alliance, and client engagement and outcomes. In the United Kingdom, Meier and Best (2004) have also shown the importance of the therapeutic relationship in engaging clients in treatment. However, there is a limited UK evidence base that examines the relationship between worker motivation for recovery and client engagement in recovery-focused services or “wrap around” provision.

10. Abstinence Is Not a Realistic Target for Most People

The target of recovery is about quality of life rather than abstinence, although abstinence may be a long-term goal for clients. However, the underlying theoretical model for much recovery work is the developmental or life-course model (e.g., Hser, Longshore, & Anglin, 2007), which would suggest a significant lengthening of the time scale for the recovery process and so the focus on change—whether to the point of abstinence—is a long-term journey that may well take up the rest of the person's life. So abstinence orientation may well be something that either does not ever occur or at least is not a viable goal. It is also this approach to “addiction and recovery careers” that means harm reduction does not have to be characterized as the antithesis of recovery.

11. Quality of After Care and Day Care Is Poor, There Is No Adequate Evidence Base, and There Is No Adequate Way of Managing Risk at This Point

After-care or long-term support pathways have often been seen as something of a Cinderella service but are essential for newly abstinent clients. The nature of this model and the competencies necessary to implement it are still open for debate. There is an increasingly strong evidence base (Dennis et al., 2008) showing that engagement in recovery management checkups results in significantly enhanced outcomes, while White (2007) has evidenced the added value associated with long-term recovery group engagement on treatment outcomes. In the United Kingdom, the lack of an evidence base of “after care” has meant that this form of support has been largely ignored by policymakers and commissioners, resulting in poor ongoing recovery support for individuals.

While White (2007) has argued that one of the main aims of the recovery approach is the switch from an acute to a long-term model for intervention, in the United Kingdom, it involves a change in mantra from addiction as a “chronic, relapsing condition to be managed” (O’Brien & McLellan, 1996) to a complex problem for which management should be characterized by “hope, dynamism and choice.” It also means a shift in roles with professionals moving from being the “directors” of change through clinical intervention to facilitators of a self-directed change that is grounded in the family home and the local community, not the hospital or clinic. This will also require a genuine multidisciplinary model in which the expertise and central role of housing, family support, education and training, and community engagement are seen not only as key partners but as equivalent experts, a role that needs to be extended to family members and peer supports within a long-term recovery model.

For those clients who are safely maintained and who have no desire to change, the Recovery Agenda would focus on providing supports (in their family and community more than in treatment settings) to improve their quality of life and aspirations. Gossop (2007) referred to the “clinical fallacy” as the learned pessimism of addiction workers whose worst fears (and stereotypes) are confirmed by seeing clients stuck in treatment or failing and coming back while they have little exposure to the “communities of recovery” that exist outside the walls of professional treatment providers. In this context, communities of recovery mean not only the formalized mutual aid groups but the totality of community-based peer supports available to individuals in recovery. One of the main challenges of the Recovery Agenda is to break down those walls so that:

• professionals spend more time in the communities they work in (by doing community clinics, spending time with local mutual aid, third sector, and community groups), and by working toward real partnerships with these people.

• recovery champions, community groups, and mutual aid groups are parts of the support and therapeutic packages in formal treatment services.

• celebrating recovery and having recovery champions are a core part of the treatment experience in all services.

The evidence base supportive of 12 step—from MATCH and UKATT (UK Alcohol Treatment Trial) among other major studies—is very strong and clearly outlined in Keith Humphreys's key text Circles of Recovery (2004). Unlike the United States, there is a major cultural issue in the United Kingdom with mutual aid having a tradition that is strong but largely independent of professional treatment and with almost no UK evidence about the impact of 12 step, in spite of some supportive evidence from the NTORS (Gossop et al., 2001) with drug users and from an outcome study with problem drinkers leaving inpatient treatment (Best et al., 2001). The perceived religious or spiritual qualities of the 12-step program with a disease model may have been an obstacle for closer working between the fellowships and statutory services. Although most clinicians will be aware of the evidence base around AA/NA, relatively few may have attended a meeting. This may represent an opportunity for the future.

However, there is a lack of adequate evidence around recovery-oriented services, which reflects two things: one, previous research funding decisions, which have largely ignored the need for a research framework outside traditional medical and treatment questions; and two, adequate consideration of what kind of evidence would be supportive. The addictions field has been largely influenced by Cochrane-type evidence hierarchies, yet it is unlikely that such a model will be appropriate for recovery research (randomized clinical trials are not consistent with self-determination and choice models), and so one of the aims for a recovery framework will be an analysis of evidence status and impact. This will also involve exploring a range of methodologies and resisting the notion of an evidentiary hierarchy that places randomized clinical trials at the summit.

The history of the mental health field provides a major challenge. “A Common Purpose: Recovery in Future Mental Health Services,” a joint position paper by the Care Services Improvement Partnership, the Royal College of Psychiatrists, and the Social Care Institute for Excellence (2007), suggests that there is a lack of empirical evidence around recovery in mental health. The position paper asserts that “the recovery literature has arisen largely from personal experience with more [recognizably] scientific evaluation and theory following later, and although rich in personal meaning it remains light on systematic analysis” (2007, p. 5). The development of a credible and quantitative evidence base is a major challenge to advocates of recovery, and it is essential that recovery-related outcomes are evidenced and mapped. These will include recovery pathways, addiction careers, recovery catalysts, and the social and psychological correlates of recovery journeys.

A further obstacle, and one articulated in White's interviews in the monograph “Perspectives on Systems Recovery” (White, 2008), is the argument that “we already do recovery.” There is a linked argument that structured treatment services provide the basis and then it is the job of “ancillary services” to do the recovery component of the client work. The first issue creates a fundamental question about whether professionals can “do” recovery to people and if so what this might mean, and the second is that there is clear evidence that sign-posting to housing, education, etc. (Best et al., in press) is neither assertive enough nor effectively owned to be a meaningful part of a recovery process. “Ancillary services” as traditionally conceived also fail to include indigenous peer-based recovery support and larger strategies of community development that help create social environments in local communities that are conducive to long-term recovery. The Recovery Movement needs to be very clear that recovery is everybody's business in the interests of developing a vibrant recovery-centered treatment service.

Although there is recognition that people may well need more than what is on offer in statutory drug services in the United Kingdom (a fortnightly chat with a drug worker lasting for 45 minutes on average and a prescription of methadone or buprenorphine; Best, Day, 2009), this is often not seen as the job of drug workers or drug services. Although there has been a longstanding movement to place the client in charge of their care plan, the recovery model requires professionals to take a further step to work alongside their clients in a coaching role.

One of the key questions for a recovery model is what a recovery partnership would look like across professional agencies, what role community organizations would have in this, and to what extent this partnership is led by real and meaningful choice (and guidance) for the recovering person. There is a clear process evaluation and research agenda around systems and structures about what is recovery oriented about treatment as it is currently delivered and how recovery systems can build on existing strengths.

C. Pragmatics—We Don't Have the Time

12. The Culture of Addiction Treatment Is Not Sympathetic to Recovery Models

The heavy reliance of prescribing as a core component of treatment system delivery (Best, Day, 2009) is partly predicated on financial constraints but also on a belief system that is culturally embedded and ingrained in the workforce and many of the clients. Challenging this model is an enormous challenge to the recovery field.

13. Clients Do Not Want All That Other Stuff—Most of Them Just Want a Script and to Be on Their Way

Clients have the right to choose what they want from treatment. Some may be at a stage of their recovery journey where they view a prescription as their main goal, and at this stage, supporting their families and carers may have primacy. There is another question to ask, and that is whether the options offered are attractive enough.

14. We Have Tried Community/Residential Rehabilitation, but There Is No Demand for It

The demand for residential rehabilitation usually outstrips supply in most areas resulting in decisions taken by a panel with criteria often unclear.

15. Recovery-Oriented Treatment Is So Expensive It Is Unrealistic

Recovery-oriented treatment poses many challenges for professionals in addiction treatment. It will require them to think both creatively and flexibly about how this can be delivered without additional expense. However, the model of peer engagement and community focus means that much of the resources required are already out there in the form of graduates of services and members of mutual aid groups and that the professional additions may well be about effective linkage to community development programs (as outlined in the seminal work on community psychology by Orford, 1992).

16. My Job Is to Treat People's Addictions—Not to Turn Their Lives Around

Recovery looks holistically at a person's life and well-being. It does not pose a responsibility on the clinician to turn a client's life around. It does need clinicians to raise their client's hopes and aspirations and to act as a coach and facilitator to help them finds ways to change their lives positively.

17. I Am Going to Lose My Job if We Have a Recovery Model; There Is No Place for Professionals in Recovery Systems

The place for professionals in recovery systems will change, necessitating changes in both culture and practice. Professionals who embrace recovery concepts and work with their service to implement these changes look forward to an exciting and dynamic time that will bring many personal and professional challenges. The public policy evidence, particularly in times of recession, do not allow us to assuage such concerns, although it is the aim of the recovery movement that this is a shared undertaking that requires a wide range of professional and community skills and resources.

As White (2007) has pointed out, the effective linkage of clients into recovery groups is not straightforward and assertive linkage will often be necessary. Timko and colleagues (2006) assessed the effectiveness of “intensive referral” to 12-step groups among treatment patients and found that not only were more assertive (peer-based) supports for attendance effective in improving meeting attendance but this also translated into better drug and alcohol outcomes. Thus, one of the key challenges in the United Kingdom at a systems level is to attempt to address interagency working as genuine partnership but also to tackle organizational cultures that are resistant to such approaches. This has, at its heart, key principles of:

• multi-disciplinary working.

• no single organization having “ownership” of cases.

• client at the center of the treatment process.

• training and supervision for workers based around active client engagement.

• rapid transition from professionally directed treatment plans to client-directed recovery plans.

• treatment systems commissioned to incorporate joint working.

• real pathways for clients and real choices right from the start.

• community, family, and peer participation in recovery programs.

A bar to the implementation of recovery-oriented systems may be the focus on individual provider service outcomes rather than the working of the wider treatment but also how this links into the wider community. Change is unlikely to occur without prescribing treatment services and without mutual aid groups and the wider community taking steps toward each other by working to the shared goal of a recovery-oriented system.

A further barrier to implementing these changes may be differences in culture and treatment philosophy, and an initial step to overcoming this may be in establishing a shared language. Prescribing services will have well-established evidence-based treatments with robust governance structures but may place less primacy on recovery goals or sometimes the self-determination of clients. Rather than supporting positive risk taking, governance may be cited as a reason why system change is not possible. Equally, mutual aid and other community services may struggle with the level of documentation necessary in statutory services as well as a perceived exclusive language.

Overcoming these obstacles requires respectful dialogue between all elements of the treatment system. This will no doubt pose many challenges, not the least of which is that agencies may view each other as future competitors in tendering processes, but with a common vision of growth in “recovery capital” and not just a reduction in pathology and symptoms, this is possible. We need a coherent model of how recovery occurs and what role different parties and organizations can play in providing the ground on which clients drive their own recovery agenda. There is a need for different assumptions about the role of treatment and for evidence on the impact of communities and families in driving recovery forward.

Crucially, there is also a cultural need to address the oppositional nature of the debate in the United Kingdom. Many proponents of recovery—including a number of Recovery Academy members—have promoted recovery communities as an alternative to an inept treatment model, while others see them as supplementary. This is counterproductive, as are the harm reduction/abstinence and recovery/maintenance models. It is essential that the Recovery Agenda is open to a wide range of players and include an agenda to map and measure medicated recovery where individuals believe this to be their experience, and that the agenda avoid the exclusionary and confrontational models that have led professionals to feel disempowered by the recovery movement as something from which they are excluded. Part of the academic foundation for the recovery movement is recognition of the longitudinal nature of addiction careers (Hser et al., 2007) and the need for different approaches at different stages of the recovery journey. There is nothing incompatible with maintenance on methadone and recovery—as long as it is delivered as part of a package of client-led recovery-focused, dynamic, and positive treatment.

Recovery as Charlatanism

18. The Current Recovery Movement is Just a Fad—We Have Done This All Before, and Soon We Will Be Back to a Medically Dominated Model

19. We Have Been Down This Road Before—With a Social Care Model, and It Did Not Work Then—Why Should It Be Any Different?

20. There Is Nothing Measurable About Recovery—Everybody Has Their Own Definition and the Rest Is All Just Talk

21. You Should Be Ashamed of Yourselves—You Are Giving People False Hope

Hope and aspiration are central tenets of the Recovery Agenda. Hope for the future to be different or better is a core feature that motivates us to make changes. The recovery coach is there to support the client in taking small steps toward their desired changes, and while this is unlikely to be a linear process, hope should remain a central feature.

22. Although Some of These Things—Recovery Cafes, Recovery Marches—Might Work in the United States, They Would Not Work in Salford, Sparkbrook, or Shettleston

Translating practice from the United States may indeed require changes to be made to recovery cafes and marches. However, these are now beginning to happen in the United Kingdom, and knowledge from these sites may help other areas implement these changes.

23. Your Talk of Recovery Is Fooling No One—This Is an Abstinence-Driven, Moral Crusade Against Harm Reduction

24. Recovery Is Also a Thinly Veiled Part of a Political Move to the Right in Drug Policy and Is a Challenge to the New Labour Approach of Harm Reduction

25. Let Us Get on With the Important Stuff of Treating People While You Can Mess Around With Your Ideas of Recovery

There is a genuine concern that we have been down a broadly social model before in the addictions field and that this proved to be unsuccessful. While there are fundamental differences about the Recovery Agenda—networking community support, the development and nurturing of recovery communities, and crucially, the concept of developing recovery-oriented systems of care—these things are not without their challenges, and there is a need for evidence around each of these questions. Pilot work is underway in the northwest of England to develop commissioning systems based on the Recovery-Oriented Integrated Systems model developed by George de Leon (2000). This is based on the idea that enabling recovery requires not only the input of workers and peers but also a systemic approach in which services are designed and aligned to maximize recovery capital and to facilitate pathways to sustainable recovery. One of the major systems challenges is to work toward baskets of indicators that will map the outputs achieved in such systems and their links to quantifiable markers of individual and community recovery.

This development of an evidence base that matches different levels of activity as outlined below is also crucial in challenging some of the more fundamental myths. Thus, in the United Kingdom, the basic challenges to be addressed to provide professionals with evidence around recovery are:

• to demonstrate that people (who have “really” been addicted) can achieve lasting recovery—and can do so by a variety of evidenced models.

• that families and communities have a core role to play in sustaining recovery in those who achieve stability and sobriety.

• that recovery communities can reduce the likelihood, duration, and severity of lapses.

• that the communities where such recovery occurs improve as a result and that community health is included within the relevant performance management models.

• that recovering addicts are an active part of communities in recovery and that this can challenge the stigma of addiction in those communities.

• that this can be done at no added cost.

• that professionals can play a critical role in enabling and supporting the early stages of recovery journeys and may also have important roles to play in the later stages of recovery.

• that systems of recovery can be supported and commissioned and that there is nothing incompatible about effective and safe medical treatment and community and peer-based recovery systems.

There are already things happening in the United Kingdom that seemed unlikely a few years ago—a vibrant online recovery Web site (Wired In), a recovery march (held in the autumn of 2009, with another larger walk successfully held in Glasgow in September 2010), recovery cafes, and a recovery forum in the northwest of England with more than 400 members.

CONCLUSION AND OVERVIEW

The evolution and funding of drug (and to a lesser extent, alcohol) treatment services in the United Kingdom has had unintended but unfortunate consequences for recovery in the United Kingdom. “Mainstream” drug treatment is often provided through NHS health and social care staff who have traditionally worked predominantly with other statutory partners and are new, and perhaps sometimes resistant, to engaging outside this milieu. Yet the transition to a recovery system is, in part, a process of learning and culture change for providers and policymakers, and part of this approach is to challenge shibboleths and received wisdoms in favor of models of working that are shared and designed for the benefit of service users.

Many community and mutual aid groups have found it difficult to access funding support and to make effective links with statutory agencies and, again, may be resistant to this. The result is the work can occur in “silos” when they could be key referral agencies and recovery partners. A further consequence has been that in some areas an “oversight” model of prescribing has developed with a mantra of “chronic relapsing condition” with a loss of the hope and vision that may be central to recovery journeys.

The purpose of this article was both to outline the situation in the United Kingdom and to challenge the myths that have perpetuated this limited model of addiction and resulting treatment. This is not new: In relation to system transformation in mental health to a recovery focused model, Davidson, O’Connell, Tondora, Styron, and Kangas (2006) listed a “top 10” concerns expressed about recovery approaches. These were:

• Recovery is old news.

• Recovery adds to the already considerable burden on mental health professionals.

• Recovery means cure, and many clients are too disabled.

• Recovery happens for very few people with serious mental illness.

• Recovery in mental health is an irresponsible fad.

• Recovery only happens after active treatment.

• Recovery can only happen with extra money for new services.

• Recovery-oriented services are not evidence based.

• Recovery devalues the input of professional staff.

• Recovery increases exposure to risk for clients and professionals.

This list was summarized by the authors as relating primarily to resources and to risk, and it is largely consistent with that identified in the current article in relation to the recovery approach in addiction.

To promote recovery adequately, it is essential that we provide a coherent and accessible evidence base that has local resonance and that also acknowledges failures in recovery endeavors and the things we cannot yet say because of a lack of evidence. One of the responses to this has been the birth of a UK Recovery Academy which aims to add to the evidence base through robust research, to stimulate debate, and to enhance communication between all stakeholders. While policymakers have begun to recognize the power of recovery as a community-driven approach, there remains a fundamental challenge to engage all areas of the treatment and wider community. This must be addressed if recovery opportunities are to be maximized for those in active alcohol and drug addiction. The Recovery Agenda is largely about client choice and empowerment (Slade, 2009), and the longer-term perspective implied in the recovery model allows for a wide range of interventions (harm reduction as well as abstinence oriented) to be available to different people at different times within a recovery system of care.

In part, this will be about breaking down the “oppositional” thinking that is prevalent in the United Kingdom where abstinence and harm reduction, maintenance and recovery, are seen as not only incompatible but as fundamentally opposed philosophical models of addiction and its treatment. There is a major process of awareness raising that is required to challenge this thinking and to break down the resulting barriers between health and social care on the one hand and communities and mutual aid groups on the other. Linked to this is a model of client self-determination and a perception in the United Kingdom of “paternalistic” treatment and “expert” status of the worker and doctor—part of the switch to a recovery-oriented culture will be an acceptance of the limited application of clinical expertise within the individual recovery journey and the broader community of recovery. It is through challenging this status and the resulting separation that the real partnerships—between workers and clients, between people in recovery and their communities, between health providers and community groups—will become possible.

These are real concerns that people have that should be taken seriously, that go beyond resistance to change. Not only do many workers fear for their jobs in such a new model, but for many, there is a real concern that their efforts and achievements in recent years are to be dismissed as “population management” strategies designed to prevent recovery by overmedicating drug clients. Thus, our approach must be supportive and conciliatory and, where revolutionary, must be embedded within an overall evolutionary model. While the switch to a recovery-oriented system of care will involve fundamental realignment of system and structure, and there is no escaping the fact that center stage will no longer be the preserve of the psychiatrist and the drug worker, their engagement is essential and their roles every bit as necessary, albeit with a different focus and with a recognition that it is the person in recovery who will be at the center of the recovery system. There is scope within the current UK approach to social care, and the recovery model is broadly consistent with a social care agenda in the United Kingdom that is switching increasingly toward self-directed care and a direct payments mechanism.

This article is limited because it is rhetorical and discursive but overall optimistic in nature. It acknowledges the presence throughout the treatment system of individuals who believe that recovery-oriented systems of care have the ability to promote hope, offer real choice, and support lasting change. This process begins with debate and engagement with the issues in the United Kingdom. This is likely to be challenging and inspirational in equal measure for the UK workforce, but the end results of working in hopeful, aspirational services that help clients make positive changes must surely be motivation enough.

Notes

1. Although there is a strong tradition of Alcoholics Anonymous (AA) in Scotland, this has been poorly researched and evaluated, and this is also true of the growing network of Cocaine Anonymous and Narcotics Anonymous (NA) groups. Scotland also has a rapidly evolving network of Self-Management and Recovery Training (SMART) Recovery meetings.

2. The majority of the evidence cited by Humphreys related to AA, with smaller supporting evidence bases for other forms of mutual aid and community support.