Better than well recovery, attraction, coercion, and the elephant in the room

Nicholas Kristof shares his experience attending a graduation ceremony for Women in Recovery, a program for court-involved women in Oklahoma.

As I watched the graduation, my imagination soared: What if everyone with a drug problem who was caught up in the criminal justice system had access to a comprehensive and long-term recovery program like this?

. . .

Future generations won’t understand how America could tolerate more than 100,000 overdose deaths a year and shattered families across the country, plus the crime and homelessness that flow from addiction. It should be a national scandal that fewer than one-quarter of Americans with substance use disorder get treatment. That’s partly because some people resist help, but perhaps one factor behind our pathetic national response is hopelessness, a misperception that nothing works.

The Addiction Recovery Story We Don’t Hear Enough. (2024). The New York Times.
‌

What’s most striking in the story are the descriptions of rebuilding lives and families. These women are better than well (more here) and the ripple effects in their families, communities, and workplaces is very easy to see and imagine.

Too often, coverage of addiction treatment reduces effective treatment to a low-intensity medical intervention of prescribing the right medication, maybe with some adjunctive peer coaching.

This may be effective for uncomplicated mild to moderate cases of substance use disorder, and medication may be essential for many people with high severity, high complexity, high chronicity substance use disorder, but this story highlights the necessity for nonmedical treatments and interventions to help people recover and flourish.

Kristoff responds to the elephant in the room — that these women are coerced into the program with the threat of incarceration.

Yet let’s be honest. Women adhere to the tough regimen and stay sober in part because they know that if they fail they will be sent to prison. So liberals like me who oppose the war on drugs must face an awkward question: Would this program be cost-effective and succeed if the alternative weren’t prison?

Many participants in Women in Recovery told me that they worked so hard to enter the program — and then to stay in and succeed — in part because otherwise they would be incarcerated. That said, they added that there were other important reasons they wanted to enter the program and overcome addiction. They were afraid of overdoses. They yearned for normal lives. Perhaps more than anything, they wanted to be reunited with their children and be good moms. So on balance, they believed that the program would still work without the threat of incarceration.

That proposition was tested when Oklahoma drastically eased its drug laws in 2016. Women in Recovery has still hummed along. I suspect that it may be a bit more difficult to replicate the success of Women in Recovery in states with lenient drug laws, but that this would not be a major obstacle.

The Addiction Recovery Story We Don’t Hear Enough. (2024). The New York Times.

This question of coercion is an important one for multiple reasons:

• It raises concerns about the infringement of liberties.
• It reflects a failure to attract and engage people in the early and middle stages of progression.
• The historical relationship between drug law prohibition and mass incarceration in the United States.
• The contemporary and historical racial disparities in incarceration and policing.

I’ve previously written about coercion in physician health programs, and about it in more philosophical terms here and here.

20 years ago, Bill White called on treatment providers to focus on attraction and engagement earlier in earlier stages of problem development, rather than relying on coercion in later stages of problem progression. (These calls were part of a larger effort to shift from acute care models to models of long-term recovery management.)

The acute care (AC) model of intervention is essentially crisis oriented. It relies on internal pain or external coercion to bring individuals to treatment, and places the responsibility for motivation for change squarely and solely on the individual. It assumes that people move from addiction to recovery when the pain of the former state reaches a point of critical mass. The AC model is also characterized by a high threshold of engagement (extensive admission criteria and procedures), high rates of client disengagement (terminating services against staff advice) and high rates of client extrusion (“administrative discharge” for noncompliance). In contrast, the recovery management (RM) model is characterized by assertive models of community outreach, pre-treatment recovery support services, and the resolution of personal and environmental obstacles to recovery. Motivation for recovery is not assumed to be static — a dichotomous (“you have it or you don’t”) entity — but is an entity that emerges out of and is sustained by an empowering service relationship. It is assumed that such motivation waxes and wanes and that active recovery coaching can help the client transcend periods of heightened ambivalence, diminished confidence, and recovery-induced anxiety.

White, W. & Sanders, M. (2004). Recovery management and people of color:
Redesigning addiction treatment for historically disempowered communities.

An important mechanism of attraction was the use of hope-based interventions. An important strategy to engage people was to lower thresholds to care.

The RM model of engagement is particularly well suited for people of color whose resistance to treatment flows from the inertia of hopelessness. Where AC models are most effective with individuals ready to take action related to their problems, RM models place great emphasis on the pre-action stages of change and the long-term maintenance stages of change. The model assumes that the scales of long-term recovery are tipped, not by the sobriety decision (alcoholics/addicts make many such decisions), but by the interaction of what precedes and follows such decisions.

White, W. & Sanders, M. (2004). Recovery management and people of color:
Redesigning addiction treatment for historically disempowered communities.

It’s important to note that these efforts to attract people and lower thresholds of engagement did not lower expectations. In many ways, the recovery management movement lowered the threshold for recovery by framing it as a process while also maintaining a high bar for recovery as an endpoint with concepts of “better than well” and integrating ideas like citizenship. (In some ways, raising the bar for recovery as an endpoint by emphasizing that there is more to recovery than abstinence.) These high expectations, along with efforts to make recovery visible in community life, were integral to kindling hope for the possibilities of recovery and flourishing.

This combination of lowered thresholds while maintaining high expectations demands a lot of treatment providers, policy leaders, and patients. They are challenged to own responsibility, rather than point to patient characteristics as primary drivers of outcomes.

Treatment outcomes are usually thought of as being determined by such client variables as problem severity or degree of motivation for change, but there is growing evidence that program and extraprogram contextual factors exert significant influences on the achievement of, or failure to achieve, long-term recovery. For example, multi-site studies of addiction treatment have linked the best outcomes to such program characteristics as clear treatment policies, high expectations of clients, highly structured treatment activities, high rates of staff in recovery, and a wider range of psychosocial services. Such positive outcomes have also been linked to broader organizational infrastructure characteristics and to the broader policy environment.

White, M. (2008). Recovery management and recovery-oriented systems of care:
scientific rationale and promising practices.

High structure and high expectations were identified as important elements in delivering good outcomes. (It’s also noteworthy that health organizations are essential to good outcomes. Not surprising to anyone familiar with the concept of parallel process.)

There is a direct connection between organizational structure, health, and functioning and client outcomes as measured by client engagement, satisfaction, and service outcomes. Programs that lack structure, high client expectations, and energetic and goal-directed staff suffer from high drop-out rates, low linkage to recovery support groups, and poor post-treatment recovery outcomes. The consistency, clarity, and strength of the program philosophy and service structure and the presence of high expectations for participation are more predictive of client outcomes than either client characteristics or the theoretical orientation of the program. Recovery management requires a stable foundation upon which long-term recovery support relationships can be built. Organizational instability and impaired organization health in the field will slow the speed of overall system-transformation efforts and the ability of organizations to implement particular technological changes in their service protocols.

White, M. (2008). Recovery management and recovery-oriented systems of care:
scientific rationale and promising practices.

At the time, Bill was contrasting Recovery Management with acute care models. We still see players and programs focused on events like naloxone distribution, naloxone rescue, MOUD initiation, 90-day retention, etc., rather than focusing on recovery and flourishing or quality of life in the context of families and communities.

Many of the challenges before us are the same ones that Bill called upon us to address 20 years ago. Of course, with the added challenges associated with the overdose crisis.

• How do we simultaneously prevent death, voluntarily attract people into care earlier in problem progression, lower thresholds to care, and maintain high expectations of systems, organizations, providers, and patients?
• How do we inspire hope and attract people into something (recovery) that we struggle to describe in concrete terms with any consensus?
• To what extent do our disagreements about expectations prevent us from developing and investing in programs that are capable of providing a pathway to the kind of flourishing and recovery that the article describes?
• How does this discord, and the resulting conflicting and muddy messages, influence public perceptions of treatment and recovery?