Recovery Management extends therapeutic reach

Lambert's PieYesterday’s post on addiction counseling as community organization got me thinking about something I’d heard from a Scott Miller presentation.

Miller argued that treatment outcomes are sue to the following factors in the following proportions:

  • 40%: client and extratherapeutic factors (such as ego strength, social support, etc.)
  • 30%: therapeutic relationship (such as empathy, warmth, and encouragement of risk-taking)
  • 15%: expectancy and placebo effects
  • 15%: techniques unique to specific therapies

Part of his argument was that we can’t control that 40% related to client and external factors, and we spend tons of time and capital arguing about the 15% related to specific therapies. He argues that we should spend much more time on the 45% we have more control over, hope and the alliance.

Here’s what I was thinking—that recovery management attends to that 45% plus the 40% Miller says is out of our hands. Bill White calls on us to shape those external factors. The attention to family, community, social, vocational, educational and other factors extends our reach.

Its worth noting that Physician Health Programs do this too, by creating social peer support (caduceus groups) and support within the workplace.

 

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Addiction Counseling as Community Organization

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A few recent posts have put Bill White’s paper on Addiction Counseling as Community Organization on my mind.

First, was a post where I wondered if we were at risk for recovery capital becoming a proxy for class. I worried that this could lower expectations for people with lower socioeconomic status and be used as a justification for different standards of care.

Then, a study on the power of access to transportation as a factor in exiting poverty. This got my gears turning about the impact of these kinds of external factors on addiction treatment outcomes.

Next was a post with a rather heated exchange in the comments that discussed socioeconomic class differences in responses to treatment and what to do about them.

And then, a friend shared this study on racial disparities in treatment outcomes:

More than one-third of the approximately two million people entering publicly funded substance abuse treatment in the United States do not complete treatment. Additionally, racial and ethnic minorities with addiction disorders, who constitute approximately 40 percent of the admissions in publicly funded substance abuse treatment programs, may be particularly at risk for poor outcomes. Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability.

And, of course, addiction treatment isn’t the only aspect of health that’s affected by class. Just today, The Atlantic posted the following:

Brookings economist Barry Bosworth crunches the data on income and lifespans for the Wall Street Journal, and the numbers tell three clear stories.<

  1. Rich people live longer.
  2. Richer people’s lifespans are growing at a faster rate.
  3. The problem is worse for women than for men.

What do we do about this? Do we lower our hopes and expectations for people with lower socioeconomic status?

The Health Affairs article on disparities calls for more services:

States could also offer providers incentives to address barriers to completion of outpatient treatment. For example, homelessness and low education are particularly prevalent among blacks and Hispanics and are contributors to lower completion rates in these groups. Future research might explore whether broadened access to resources such as supported housing and vocational training are cost-effective strategies for improving outcomes and reducing disparities. Efforts to improve the tracking of individual patients could increase retention and improve outcomes, particularly for homeless populations.

Bill’s emphasis is a little different. He calls on us to raise our expectations of ourselves and the system while focusing on recovery and the community as the locus of healing. (Rather than emphasizing treatment at the expense of wellness and glorifying ourselves.) [emphasis mine]

Addiction treatment must always adapt to the evolving context in which it finds itself. Such redefinition may push treatment toward the experience of retreat and sanctuary in one period and toward the experience of deep involvement in the community in another. I would suggest that the focus of addiction counseling today should not be on addiction recovery-that process occurs for most people through maturation, an accumulation of consequences, developmental windows of opportunity for transformative or evolutionary change, and through involvement with other recovering people within the larger community. The focus of addiction counseling today should instead be on eliminating the barriers that keep people from being able to utilize these natural experiences and resources. Our interventions need to shift from an almost exclusive focus on intervening in the addict’s cells, thoughts and feelings to surrounding and involving the addict in a recovering community.

6a00d8351b273153ef01156f302741970c-800wiIn another paper. Bill White identified 4 tasks of treatment and recovery:

  1. Recovery from the other genetic, biochemical, social, psychological, or familial influences which initially contributed to the development and trajectory substance problems
  2. Recovery from the adverse psychosocial consequences of the substance use
  3. Recovery from the pharmacologic effects of the substances themselves
  4. Recovery from an addictive culture

When I saw this list for the first time, I was struck by the intuitive truth it organized and articulated. I was also struck by how it illuminated the scope of the treatment and early recovery—”social, psychological, familial . . . psychosocial consequences . . . addictive culture”.

That paper on Addiction Counseling as Community Organization was really an early step in the development of his concept of Recovery Management, which is explained more fully here. In this paper, Bill shifts the language to “community renewal.”

A major focus of RM (Recovery Management) is to create the physical, psychological, and social space within local communities in which recovery can flourish. The ultimate goal is not to create larger treatment organizations, but to expand each community’s natural recovery support resources. The RM focus on the community and the relationship between the individual and the community are illustrated by such activities as:

  • initiating or expanding local community recovery resources, e.g., working with A.A./N.A. Intergroup and service structures (Hospital and Institution Committees) to expand meetings and other service activities; African American churches “adopting” recovering inmates returning from prison and creating community outreach teams; educating contemporary recovery support communities about the history of such structures within their own cultures, e.g., Native American recovery “Circles,” the Danshukai in Japan;
  • introducing individuals and families to local communities of recovery;
  • resolving environmental obstacles to recovery;
  • conducting recovery-focused family and community education;
  • advocating pro-recovery social policies at local, state, and national levels;
  • seeding local communities with visible recovery role models;
  • recognizing and utilizing cultural frameworks of recovery, e.g., the Southeast Asian community in Chicago training and utilizing monks to provide post-treatment recovery support services; and
  • advocating for recovery community representation within AOD-related policy and planning venues.

It can be overwhelming. But, the alternative is despair.

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Should we lower the bar?

Lowering_The_Bar_Cover_2010.09.22USA Today ran a story about problems in the monitoring of impaired physicians.

Many states lack rules to ensure that medical facilities alert law enforcement or regulatory agencies if they catch employees abusing or diverting drugs, so those staffers often are turned loose to find new jobs without treatment or supervision. Disciplinary action for drug abuse by health care providers, such as suspension of a license to practice, is rare and often doesn’t occur until a practitioner has committed multiple transgressions.

“We certainly see gaps in the system; the examples are many,” says Joseph Perz, an epidemiologist at the U.S. Centers for Disease Control and Prevention.

The challenge in addressing the problem is finding a “balanced approach,” Perz adds. “We recognize that addiction is a disease and we recognize the value in … (rehabilitating) a provider. At the same time, we need to be thinking about the potential harm to patients. That balance is difficult.”

One disappointing part of the story is that they failed to discuss the fact that, once they get into physician recovery programs, physicians have extraordinary treatmet outcomes.

The paper posted the following question on twitter: “Thousands of drug-addicted doctors, nurses escape notice, endangering patients, report reveals. What should be done?”

Thank goodness this isn’t actually the approach we take with addicted doctors:

Too bad it is the approach we’ve taken with other patients.

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Comic relief

Leave it to the Onion to make incisive commentary about the recently unveiled medical marijuana vending machines in Colorado:

“Nothing legitimizes medicine like selling it from a vending machine.”

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The latest on Phillip Seymour Hoffman

imagesAfter all the speculation that Phillip Seymour Hoffman could have been saved if he had been placed on Suboxone, we have one more bit of information. Not only did he have the drug in his apartment, he had enough exposure to recommend it to a fellow addict.

Sometime last year, he met Mr. Hoffman through mutual friends. They were kindred spirits, he said, both private people. He avoided questions about whether the two used drugs together. But he said they talked and exchanged text messages about their addictions, with Mr. Hoffman urging Mr. Aaron to try Suboxone, a controversial prescription painkiller used to treat heroin addiction. The messages ended last fall, when the two men fell out of touch, Mr. Aaron said. Then, at the beginning of February, Mr. Hoffman died of an overdose of multiple drugs.

I’m not arguing that the drug killed him. Just that the arguments that “abstinence-based/12 step domination” in the treatment industry killed him is a bogus argument.

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Gratitude cultivates patience

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A recent study suggests that gratitude fosters longer term thinking and patience. Traits that are undoubtedly helpful in recovery.

My colleagues Ye LiJennifer LernerLeah Dickens, and I decided to test how the experience of gratitude effects discounting and financial impatience. We designed an experiment (now in press at the journal Psychological Science) that presented participants with a set of 27 questions, which pit a desire for immediate cash against a willingness to wait for larger rewards at various times in the future. For example, one question required study subjects to choose between receiving $54 now or $80 in 30 days. To increase the stakes, participants knew they had a chance to obtain one of the financial rewards they had selected; it wasn’t purely hypothetical. If they chose the immediate cash, they’d be paid then and there; if they chose the delayed amount, we’d send them a check. However, before they made these decisions, we randomly assigned each one of them to recall and briefly write about an event from their past that made them feel (a) grateful, (b) happy, or (c) neutral.

As we expected, individuals who wrote about neutral or happy times had a strong preference for immediate payouts. But those who’d described feeling grateful showed significantly more patience. They required an immediate $63, on average, to forgo receiving $85 in three months, whereas the neutral and happy groups required only $55, on average, to forgo the same future gain. Even more telling was the fact that any given participant’s degree of patience was directly related to the amount of gratitude he or she reported feeling. It’s important to note that positive feelings alone were not enough to enhance patience: Happy participants were just as impatient as those in the neutral condition. The influence of gratitude was quite specific.

We see broad implications for these findings, since they suggest that gratitude can foster long-term thinking. We all recognize the fact that willpower can and does fail at times. Having an alternative source of patience – one that can come from something as simple as reflecting on an emotional memory – offers an important new tool for long-term success. And that itself is something to be grateful for.

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Embrace harm reduction?

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DJ Mac challenges recovery-oriented providers to embrace harm reduction:

Despite my focus on recovery I have a strong harm reduction ethos at my core. Sure, I challenge services to be recovery-orientated, but I firmly believe that the reverse needs to be true. Rehabs and other services with a recovery goal ought to have harm reduction practices woven into their fabric. If they don’t they could be short-changing clients.

Read the rest here.

Spend some time on his blog. His posts are consistently smart, challenging, concise and he avoids the simplistic and false binary arguments that plague writing on the topic.

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