Recovery: The bridge to integration?

Bill White and Larry Davidson suggest that shifts toward recovery orientation models in mental health and addiction services could serve as a bridge toward integration:

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Theoretically, I don’t disagree at all. My fear is that this process will not be a merger between equals, my experience (admittedly limited to southeastern Michigan) is of watching mental health systems devour addiction treatment systems. This fear is compounded by the fact that, at least in our region, mental health agencies are well-organized and well-connected governmental behemoths while addiction treatment programs are small, unstable and diffused.

Consider these historical reflections from some of Bill’s other works:

The Segregation/Integration Pendulum
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Diffusion and Diversion
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.

A Panicked Field In Search of Its Soul and Its Future
In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.