Davidson: Integrating Recovery Supports in Recovery-Oriented Systems of Care

NYAPRS Note: Here’s an excellent, timely and thought provoking piece by Larry Davidson (of Yale University and project director for SAMHSA’s and DSG’s Recovery to Practice Initiative) that emphasizes the ‘dance’ necessary to address both people’s addiction and mental health conditions and the broader contexts in which they live and that help define the quality of their lives, e.g. the ‘social determinants of health’ like housing, economic, educational and social statuses, as well as their connection to culture, peer support and spirituality.


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July 5, 2012

Volume 3, Issue 25

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Integrating Recovery Supports in Recovery-Oriented Systems of Care

by Larry Davidson, Ph.D.

Last February, SAMHSA announced its new action plan, Leading Change: A Plan for SAMHSA's Roles and Actions 2011–2014, which identified eight strategic initiatives. Recovery Support, the strategic initiative most relevant to RTP, is described as "partnering with people in recovery from mental and substance use disorders and family members to guide the behavioral health system and promote individual-, program-, and system-level approaches that foster health and resilience; increase permanent housing, employment, education, and other necessary supports; and reduce discriminatory barriers." So, what are recovery supports? Why do we need recovery support services to foster health, resilience, and recovery? And what do these services have to do with recovery-oriented practice within the context of recovery-oriented systems of care?

What Are Recovery Supports?

Use of the terms "recovery supports" and "recovery support services" is a relatively recent development in the behavioral health field. Recovery support services refer to community-based supports that enable people to acquire various forms of recovery capital—the sum of social, emotional, informational, instrumental, and "affiliational" support a person can use to initiate and sustain recovery. The forms of recovery capital are diverse. Examples include a reawakening of hope; obtaining safe and stable housing; securing employment or returning to school; developing a sense of efficacy, personal agency, and self-confidence; connecting with a faith-based or spiritual community; obtaining child care and parenting assistance; securing transportation; increasing motivation for behavioral change; and securing a network of supportive peers and friends.

Despite the fact that the term "recovery support" is relatively new, some of these services have been around for a while. But such supports have traditionally been described either in terms of a specific intervention (e.g., supported employment, supported housing) or grouped together under different concepts, such as those of mutual aid organizations in the substance use field (including Alcoholics Anonymous and other 12-step fellowships) or "peer-run" programs in the mental health field. In this sense, recovery support services have been available to people with substance use conditions for at least 80 years and to people with mental health conditions for at least 40 years. Why, then, would we introduce a new term for what some people might consider to be old practices and activities?

Why Do We Need Recovery Support Services to Foster Health, Resilience, and Recovery?

One reason for the new term is because much has changed in the behavioral health field since the 1930s, including the very use of the term "behavioral health." In many ways, mental health and substance use treatment were two entirely different fields with very little in common. Although 12-step groups may have cropped up throughout the country to promote the notion of "recovery," the substance use treatment field largely disregarded advances in the provision of community-based supports for housing, employment, and education. At the same time, the mental health field was developing these types of supports, but lacked any sense of the possibility of "recovery" for people with serious mental illnesses. It has taken recovery movements in both fields, led by people in recovery from either or both conditions, to change this picture in a dramatic and revolutionary way. These changes have made it possible for us to refer to an integrated field of behavioral health-a field that makes central, substantial use of recovery support services.

What has changed? In many ways, the behavioral health field is being turned on its head. In the substance use field, it was customary to believe people had to lose everything and "hit bottom" before they would be willing to accept their powerlessness over substance use and be "ready" for treatment. If they did not benefit from substance use treatment, the failure could be attributed to the person not yet being ready to change. In the mental health field, it was common to believe people had to develop "insight" into their condition, accept having a mental illness, and comply with treatments (primarily medications) to achieve clinical stability-the best they could hope for in the absence of any notion of recovery. Once they achieved clinical stability, they could be referred to rehabilitative interventions that would enable them to rebuild their lives. If someone dropped out of treatment, stopped taking medication, or failed to achieve clinical stability, such failures could be attributed to the illness or to the person's lack of insight, interest, or initiative. In spite of numerous interventions that have proven highly effective, many people with substance use and/or mental health conditions have not accessed specialty care. Of those who sought out this care, many have dropped out prematurely, and few have derived the optimal benefit.

The consumer movement in mental health and new recovery advocacy movement in substance use have argued persuasively for addressing these limitations in systems of care by reversing the customary logic (get treatment first, regain your life afterward) and adopting an approach that helps people have a life and offers treatment within that context. The role of recovery capital has been central to this reversal. If a person has little to no recovery capital (e.g., is homeless, unemployed, and alienated from family), he or she has few resources to draw from when assuming the hard work of recovery, and is thus unlikely to succeed. If a person has adequate recovery capital, he or she is likelier to recover independently or with formal help. Recovery supports are crucial for people who have lost (or never really had) the recovery capital needed to set about recovery in a fully effective and sustainable way.

Understanding the need for a solid foundation upon which to build a person's recovery was missing from the history of mental health and substance use treatment. This point can be made succinctly using key terms from SAMHSA's Strategic Plan: having a home, one's health, a sense of purpose, and sense of community produce an environment more conducive to recovery than homelessness, poverty, isolation, and unemployment. In addressing fundamental life issues that historically fell beyond the scope of their practice, both mental health and substance use treatment providers found interventions classified as recovery support services were effective bridges to treatment, potent augmentations to treatment, and valuable post-treatment resources that enabled people to maintain successes they had achieved in care. For people who need a home, a sense of purpose, a sense of community, or better health, it may take a combination of recovery support services and treatment to reduce substance use and mental health difficulties while increasing their resources, skills, confidence, and social support enough to enter into and sustain recovery.

This is where the two fields have begun to converge in the past decade. The introduction of recovery support services in the substance use field has served to bridge the longstanding gap between the recovery community and clinical care. Similarly, the mental health consumer movement has been moving over the last decade toward a partnership with professionals who provide clinical care. As both recovery movements have recognized the need for integration of clinical care and community-based recovery support services, the two fields have also moved closer to each other, coming together around the concept of recovery-oriented systems of care. If recovery-oriented systems of care assign a central role to recovery support services and require them to be integrated with clinical care, one final question remains:

What Do Recovery Support Services Have to Do With Recovery-Oriented Practice?

The simple answer to this question is that the provision of recovery support services represents one key form of recovery-oriented practice. Supports and services that promote employment, housing, education, socialization, parenting, and spirituality are all recovery oriented, as are various forms of peer support, peer recovery coaching and mentoring, and peer-run programs. Crisis respite programs, sober housing, affirmative businesses, outreach and engagement, telephone support, transportation, and recovery/wellness checkups are also forms of recovery support. Some of these supports have been utilized by people with substance use or mental health conditions for decades, but even those with firm, established evidence bases attesting to their effectiveness (e.g., supported housing and employment) have yet to be fully implemented in any U.S. system. Bringing these supports to scale throughout the country is a main focus of SAMHSA's Recovery Support Strategic Initiative.

With its main focus on transforming the major behavioral health professions, RTP is also concerned with recovery-oriented practices employed by psychiatrists, psychologists, nurses, social workers, and rehabilitation practitioners. Although everything these practitioners do should ultimately support a person's recovery, not everything they do can be considered a "recovery support service" in the sense described above. So, how do recovery support services relate to the treatments, clinical interventions, and other services behavioral health care professionals provide? And what does it mean to say these services must be integrated with recovery support services within the context of recovery-oriented systems of care?

The Role of Recovery Capital suggested one difference between recovery support services and other recovery-oriented practices (such as clinical care) is that recovery support services primarily aim to increase recovery capital, while treatments primarily aim to decrease distress and sources of distress (such as symptoms). Whereas it is a somewhat useful division of labor, this distinction glosses over complexities and subtleties that arise at the interface of recovery support services and recovery-oriented clinical practices. Although they are distinct concepts, recovery capital is not so easily separated from suffering in real life, as the examples of housing and employment suggest. Helping a person obtain safe and dignified housing or meaningful employment also diminishes his or her suffering, just as increasing a person's understanding of the impact of trauma on his or her life can translate to an increased sense of purpose and community. Recovery-oriented clinicians build on strengths and foster growth while working to alleviate suffering, just as recovery support service providers lessen suffering while assisting people to obtain a home and sense of community. In real-world practice, these distinctions are not nearly so clear cut. What, then, is the difference? Perhaps focusing on a specific example will help us see how the pieces come together.

One of the six criteria for supported employment as an evidence-based practice is that job coaching is closely aligned with clinical care. If the person's clinical care is provided in a nonintegrated fashion-disconnected from the job coaching function-then this constitutes poor fidelity to a key criterion of the practice, and is much less likely to be effective. But what happens when job coaching and clinical care are integrated? How can the two be integrated when they are not provided by the same practitioner? Although it might seem ideal for one person to carry out both functions, it is unlikely that a credentialed clinician would also serve as a job coach. Not only is this not a cost-effective arrangement, but there is presently very little in the training of behavioral health care professionals that prepares them to function as community-based rehabilitation practitioners. At the same time, occupational, recreational, and psychiatric rehabilitation practitioners are not trained to perform traditionally defined clinical interventions. In this sense, the division of labor described above seems to make some sense.

How, then, can job coaching and clinical care be brought together within the context of a recovery-oriented system of care? How does a job coach work in partnership with a clinician, or a job coach and clinician work together as part of an interdisciplinary team? What about the roles of a peer support specialist, psychiatrist, or nurse practitioner? A key component of integration between clinical services and recovery support services is that all interventions are derived from a person-centered recovery plan driven by the individual and his or her goals. Everything a provider does-whether a recovery-oriented clinician or recovery support service provider-should support a person's efforts to achieve his or her life goals. Within this context, peer staff (for example) help people know they can have and deserve to have such goals to begin with, and likewise can help people identify their goals. Job coaches enter the picture when one of the goals is employment. The peer support provider and/or job coach can help the person work on his or her self-esteem before taking the next step to secure employment. In short, recovery support services support people in pursuing their hopes, dreams, and aspirations.

Often times, making progress in recovery also requires interventions to remove obstacles or overcome barriers the person encounters along the way. For example, psychiatric medications can be extremely effective for some people to decrease or eliminate distracting voices that make it difficult to concentrate. For others, cognitive–behavioral psychotherapy may help reduce intrusive thoughts, manage triggers for relapse, and enable people to recuperate after a severe depression. Interventions that remove or minimize such barriers-although not always necessary-may be instrumental for some people to function in the job of their choice. In this way, they are important components of the recovery-oriented clinician's tool box.

Still, aligning interventions from different domains and different providers with a person-centered recovery plan alone is not adequate for ensuring integrated care. People and behavioral health conditions are far more complex and dynamic. What if the prescribed medications, for instance, not only decrease disruptive voices but also make the person feel so tired that he or she cannot get out of bed to go to work? What if the person is not interested in taking medication to decrease hallucinated voices because the voices are his or her major source of company? Although getting a job could offer that individual a new social network to eventually replace the voices, it would be difficult to do so while the voices were significantly distracting. These complexities may only be the tip of the recovery iceberg, suggesting the need for ongoing and close communication between the person, job coach, peer support provider, clinician, and psychiatrist or nurse practitioner.

In such cases, recovery support services that aim to enhance real-world functioning may be limited in effectiveness by unaddressed barriers that stem from a mental illness, an addiction, or another source. And clinical care that aims to decrease suffering, symptoms, and substance use may be limited in effectiveness by the person's unaddressed needs for recovery capital (in this case, social support and self-confidence). The need to address aspirations and barriers and functioning and illness means recovery-oriented practice must be a dynamic dance that often involves more than two partners. Ensuring the dance is recovery oriented and integrated requires all parties to dance to the same song, with the music and pace chosen by the person him or herself.

Larry Davidson is the Project Director for RTP.

Additional Reading:

Davidson, L., W.L. White, D. Sells, T. Schmutte, M.J. O'Connell, C. Bellamy, and M. Rowe. (2010). Enabling or Engaging? The Role of Recovery Support Services in Addiction Recovery. Alcoholism Treatment Quarterly 28:1–26.

Kaplan, L. (2008). The Role of Recovery Support Services in Recovery-Oriented Systems of Care. HHS Publication No. (SMA) 08-4315. Rockville, Md.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention.

White, W.L. (2009). Peer-Based Addiction Recovery Support: History, Theory, Practice, and Scientific Evaluation. Philadelphia, Pa.: Great Lakes Addiction Technology Transfer Center and the Philadelphia Department of Behavioral Health and Mental Retardation Services.