The allegory of the lake: The implications of an Inclusive Recovery Cities model for prevention and early intervention

Position Paper: Centre for Addiction Recovery Research

(by David Best)

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Rationale and background: The inclusive cities model was originally conceptualised by Best and Colman (2018) based on the idea that recovery is an achievement that should be celebrated in order to:

1. Challenge stigma and exclusion
2. Increase visibility of recovery and access to community resources

In the course of 2023 and 2024 there has been an explosion of interest in this topic and there are now around 30 Inclusive Recovery Cities across the UK, Ireland, the Balkan region, Belgium, Sweden and South Africa.

The approach is based on a strategic commitment to celebrating and promoting recovery through a minimum of four public facing events that are open, accessible and engaging; the result of which is to create new community assets and community connections.

So what are the assumptions of this model?

Figure 1 illustrates the basic model of addiction careers and the slow and complex journey to recovery:

The assumptions in this model are that, for many people who end up addicted, there were significant challenges (typically including traumatic events) that preceded their substance use, and for which substance use provided a very temporary solution. In the lake metaphor used in this paper, ‘normal life’ is represented as the surface of the lake with most people splashing around on the surface with occasional dips under the water and peak moments of soaring above it. But the person who ends up addicted will often have struggled to reach the surface even before their substance use started and its false promise will soon be apparent as they continue to sink. For the fortunate few, early interventions or significant positive life events may act as their life raft but for many their addictions will drag them under.

We know that people will typically have around 4-5 episodes of specialist treatment over eight years (Dennis, 2007) before they will eventually start the five years of their recovery pathway. And the trouble with many of the treatment interventions is that because they primarily provide symptom reduction services, they will only temporarily help the individual back to the surface of the lake. When those complex life issues – lack of meaningful activities and a sense of purpose, lack of safe housing that is free from threat, and either social isolation or networks supportive of substance use (as well as ongoing trauma and unresolved emotional health issues) – recur, the reinstatement of substance use will result in sinking back to the bottom of the lake. And each time, the weeds and sand at the bottom will drag them further down into despair, stigma and an internalised sense of failure.

As shown in Figure 2, it is the introduction of recovery support services, generally in the form of peer-led and community-based services (Humphreys and Lembke, 2013) that will result in two things:

1. The end of the cycle of chronic relapse and brief periods of stability
2. Living above the surface of the water in a phenomenon known as ‘better than well’ (Valentine, 2011)

Fundamentally, the goal of the recovery model is to transcend addiction, not by addressing symptoms but by building strengths in a model that is referred to as ‘recovery capital’ (Granfield and Cloud, 2003). Most simply framed, the aim of the recovery model is to support people to achieve ‘somewhere to live, someone to love and something to do’ with supportive social networks and meaningful activities the ‘golden threads’ that run through the recovery literature.

The notion of capital and what it can achieve is best summarised in a quote from John Braithwaite from the Australian National University who stated that:

“Social capital, human capital, recovery capital and restorative capital are unlike financial capital in that they are not depleted through use. When you spend your money from the bank, you deplete your capital. When you trust someone, you do not deplete trust: trust tends to be reciprocated and this engenders virtuous circles of trust-building. A politics of hope is likewise redemptive as we face adversity; it is infectious” (Braithwaite, 2022, p. 363).

The fundamental shift that this implies is that, in the recovery model, there is a shift in target and beneficiaries for interventions. The assumption is no longer about helping the patient to feel better, but rather there are a complex set of echoes and cumulative gains within a recovery model that go well beyond dragging the suffering patient to the surface of the lake.

What we are trying to illustrate in Figure 3 is a much more complex implication of the social contagion of recovery which is that it raises the bottom of the lake, and so the drowning person does not have to sink so deep. And this is where Inclusive Recovery Cities have a central role to play.

So what does this mean?

One of the fundamental shifts from a treatment to a recovery mindset is the notion of cumulative impact. In the treatment approach, each individual starts from the bottom of the lake (and will only seek treatment typically when they hit a point of hopelessness because of stigma and shame about help seeking. The progress in the model is based on advances in the science of pharmacotherapy and the methods of talking therapies. In the lake model discussed here, the depth of the lake remains constant – what will change are our technical abilities to drag people to the surface.

This is not the case for a recovery model and an Inclusive Recovery City where the cumulative benefit of building community recovery capital is that the lake becomes less deep, meaning that the individual does not descent so far and that the journey back to the surface (and beyond) is not such an arduous one.

What are the grounds for such a claim? In the recovery world, the locus of action is the community and the mechanism of action is human connectedness. So as the total number of recovery groups, visible and attractive recovery champions, recovery community centres and events increase so the visibility, attractiveness and accessibility of recovery increases.

The lake becomes less deep and the safety nets more visible and accessible. But this also has an implication for prevention as shown in Figure 4:

So what recovery generally does is to increase the visibility and attractiveness of recovery by ensuring that there is a community presence and a sense that recovery is possible. What an Inclusive Recovery City adds to this is the Community Recovery Capital of increased citizenship and salience of attractive recovery events and activities that reduce social distance and stigma around both addiction and the recovery journey. This is done through increasing civic activity and engagement and by championing positive recovery events.

In Figure 4, what this means is that not only does the individual not have to experience the same depths of addiction before recovery becomes more salient and accessible, but in the addiction and recovery curve that the lake represents, the start of the ascent is earlier. Because of the community focus and positive activities and events surrounding recovery in an Inclusive Recovery City, this creates the conditions for stronger community connections permitting more effective prevention and early intervention. The lifeboat waits in the shallow waters of experimentation and occasional use rather than sending frogmen down into the turbulent depths of active addiction.

So where to from here?

We are at the start of the journey for Inclusive Recovery Cities and we are in the process of identifying appropriate metrics but the model presented here should allow us to develop core metrics around not only recovery growth, but also community engagement, public attitudes and social distance and the implications for the prevention and early intervention agendas. This is a model that will allow us to build a community-centred and recovery-oriented model of prevention and early intervention based on citizenship and active community participation and bring together a coherent model of public health and community-based approaches to tackling problematic substance use through strengths-based and whole-city approaches.

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References

Best, D and Colman, C. (2018) Lets celebrate recovery: inclusive cities working together to support social cohesion, Addiction Research and Theory, 27(1), 55-64

Braithwaite, J. (2022) Macrocriminology and Freedom. ANU Press: Canberra, Australia, Macrocriminology and Freedom (anu.edu.au).

Dennis, M., Foss, M. & Scott, K. (2007) An Eight-Year Perspective on the Relationship Between the Duration of Abstinence and Other Aspects of Recovery, Evaluation Review, 31(6), 585-612

Valentine, P. (2011) Peer-based recovery support services within a recovery community organization: The CCAR experience. In: Kelly, J. & White, W. (eds) Addiction recovery management (pp. 259-279). New York: Humana Press.