This post isn’t meant to suggest that ROSC or recovery advocacy are bad in any way. Rather, it is meant to suggest that Recovery Management has been underdeveloped while energy and enthusiasm have been focused on recovery advocacy and ROSC. It also isn’t meant to assign blame, I’m just sharing an observation.
Recovery Management (RM) refers to “a philosophy of organizing addiction treatment and recovery support services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery.” (source) Also, described as “the mobilization and integration of personal, family, professional and indigenous community resources toward the goal of enhancing the duration and quality of life of those experiencing severe and persistent behavioral health disorders.” (source)
Recovery-Oriented Systems of Care (ROSC) refers to “the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families and the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes.” (source)
The New Recovery Advocacy Movement (NRAM) referred to “a recovery movement that is affirming the very real potential for permanent personal resolution of alcohol and other drug (AOD) problems” and contrasts it with past alcoholism movement’s focus on stigma reduction as a precursor to system change “reducing stigma may be best viewed as a peripheral by-product rather than a central goal of the movement. The goals instead would be best focused on what we want people (represented collectively as communities, states and the nation) to do.” (source)
So… RM is the micro level—the model of care and recovery support that individuals and families receive, focused on facilitating long-term recovery.
ROSC is the macro level — the system makes it possible to facilitate long-term recovery maintenance from severe and persistent problems. ROSC is intended to exist in service of RM.
NRAM provides living proof that long-term recovery is possible and pressure on the system and other social institutions to remove barriers to recovery and establish services of adequate duration, intensity, and quality to facilitate permanent recovery.
The promotion of RM began around 2000 with ROSC following a few years later. RM had just been getting traction at conferences for addiction counselors when ROSC started getting promoted. It was quickly overshadowed by ROSC.
RM wasn’t well-understood or widely implemented at the program level, and suddenly, ROSC was getting all the attention at conferences and continuing education provided by the county and state. It wasn’t just policymakers and funding agencies getting all of this training, it was frontline clinicians. They were getting this macro model without the micro foundation it’s intended to be built upon.
In 2008, Bill White noted the conflation of Recovery Management and Recovery Oriented Systems of Care:
The field seems to be shifting its historical focus toward the processes of recovery initiation to pathways, patterns, stages, and styles of long-term recovery. That transition has opened the door for the concepts of recovery management and recovery-oriented systems of care, which are heard with increasing frequency but are often ill-defined or used interchangeably.
White, W. L. (2008). Toward Recovery Management and Recovery-Oriented Systems of Care Scientific Rationale and Promising Practices. Jointly published by the NortheastAddiction Technology Transfer Center, the Great Lakes Addiction Technology Transfer Center, and the Philadelphia Department of Behavioral Health/Mental Retardation Services: Philadelphia, PA.
Simultaneously, recovery advocacy and ROSC advocated for a redefinition of recovery along with the recognition, adoption, and promotion of multiple pathways to recovery. To be sure, the field needed to identify, develop, and celebrate additional pathways to recovery, but the concept of multiple pathways has devolved from matching clients with a menu of appropriate pathways to “you find whatever works for you.” As Bill White wrote in 2007, a clear definition with any consensus has been elusive.
This focus on recovery is occurring without a clear definition of recovery and at a time in which there are calls to re-examine and increase the clarity of the language used to depict alcohol and other drug problems and their resolution (CSAT, 2000; Kelly, 2004; Milgram, 2004). The lack of an accepted definition of recovery contributes significantly to the variability of reported outcomes of addiction treatment (Maddux & Desmond, 1986). The term’s conceptual fuzziness has also produced contention within recovery mutual aid groups and recovery advocacy organizations over when the state of recovery is achieved, lost, and reacquired (White, 2006a). It is not surprising in the face of such confusion that researchers tend to avoid the term, clinicians and mutual aid advocates use the term but with different meanings, and the public tends to understand recovery as an attempt to resolve, rather than the successful resolution of, AOD problems (Faces and Voices of Recovery Public Survey, 2004).
White, W. (2007) Addiction recovery: Its definition and conceptual boundaries. Journal of Substance Abuse Treatment, 33, 229-241.
In the absence of a clear consensus definition, we’ve seen a succession of definitions intended for one narrow use — recovery research, public health, engagement into peer services, affirming harm reduction — bleeding into areas outside of their intended use.
It’s important to note that the common usage of the term recovery, taken from 12-step recovery, was too narrow for broad clinical adoption or for the development of systems of care. Various interests had their own reasons for expanding the boundaries of recovery. The prerequisites were expanded from chronic and severe problems (addiction) to mild/moderate and acute problems. Additionally, recovery was expanded to include ongoing instrumental drug use as well as recreational AOD use, including heavy alcohol use.
This resurrects efforts to distinguish recovery from remission:
Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.
White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center
Further, the integration of harm reduction into the boundaries of recovery and the expansion of recovery advocacy into the rights of drug users to safe(r) supply, legal drug markets, and non-interference in drug use. This path has led to things like a prominent researcher stating a goal to “depathologize addiction.”
The failure to develop a shared definition of recovery or confine definitions to the domain for which they were intended has resulted in a recovery advocacy movement and ROSC development that lacks clear boundaries and goals. Bill White spoke about the importance and implications of failing to develop a coherent organizing paradigm.
Concerns about how the resolution of AOD problems are conceptualized and semantically expressed are far more than intellectual games played by addictionologists. The choice of concepts and language shapes the fate of those experiencing AOD problems and exerts a profound influence on institutional economies and professional careers. Recovery is resurfacing as an advocacy paradigm for reengineering addiction treatment and addiction-related social policies, but the potential of recovery as an organizing paradigm is limited by the failure to define recovery and stake out its conceptual boundaries. Such definitional and boundary setting tasks have great import for clinical research, clinical practice, recovery mutual aid, recovery advocacy, and, most importantly, for individuals and families impacted by severe AOD problems.
White, W. (2007) Addiction recovery: Its definition and conceptual boundaries. Journal of Substance Abuse Treatment, 33, 229-241. Posted at chestnut.org
So… my controversial take is that ROSC and recovery advocacy have grown without a coherent organizing paradigm while Recovery Management has withered (though it’s often conflated with ROSC). The failure to develop a clinically useful definition of recovery has resulted in the conflation of chronic/severe problems (addiction) with lower severity problems, conflicting demands from the public and funders, research with limited clinical relevance, and a failure to innovate clinically.
Worse, we’ve got a generation of peers, counselors, and other addiction professionals who have been brought into a profession where addiction, recovery, and treatment have been destabilized. This raises concerns not just about the present, but also about the future.
I don’t want ROSC and recovery advocacy abandoned; I want investment in Recovery Management. I’d love to see the adoption of a clinically useful definition of recovery, which may be different from a useful definition for research or public health. However, I’d settle for investments in innovation in assessment and the development of typologies of SUDs with appropriate clinical endpoints for each — abstinence for some, moderation for others. It’s possible a different organizing construct would be helpful; Brian Coon has proposed the Stages of Healing, Robert Strain has proposed flourishing, and others have suggested focusing on quality of life.
Recovery Review 