This foundational paper can be found in various places.
Currently, the most convenient place to find the paper is the archive of Bill’s materials at the Lighthouse website.
As of today, this link does work for free access to the full paper, from the new location archiving his papers. (The section of their website containing his papers has been in the process of being re-built from scratch for some weeks now).
- The article was published in: White, W., Boyle, M. And Loveland, D. (2002). Addiction as chronic disease: From rhetoric to clinical application. Alcoholism Treatment Quarterly, 3/4:107-130.
- It was published on-line in 2008 and remains paywalled at that location.
- The full text is available for no cost at Research Gate for those that have a Research Gate account.
When I think about the Behavioral Health Recovery Management (BHRM) project, and the few essential documents that contain its core content, this paper is always on my shortest short-list. For me this paper’s as relevant today as it was upon its release. And it’s on my shortest list of Recovery Management must-reads.
Why?
I’ll try to outline what makes this paper so essential. The paper:
- Provides a brief history of addiction as a chronic disease, starting in the 1700’s
- Compares mere rhetoric about the chronic nature of addiction illness with various clinical practices
- Establishes the foundations of a contemporary chronic disease/recovery management model
- Provides characteristics common to most chronic diseases, and compares alcoholism to each
- Gives an overview of recovery management concepts and principles
- Identifies and discusses pitfalls inherent in the challenge of implementing recovery management methods
One other portion of the paper that makes it an essential read lists and describes a set of factors to consider toward building a recovery-oriented model of care. Reading that section can help clarify opportunities and methods within each for potential innovation or improvement.
- Service Integration
- Identification and engagement
- Assessment
- Definition of “client”
- Service Goals
- Service Scope and Technologies
- Timing and Duration of Services
- Delivery Locus
- Service Relationship
- The Role of Community in Recovery
- The Recovery Management Team
- Service Evaluation
For those that would like to read more from the paper here in this post, below are some quotations from the paper. I’ve only picked a few and list them here as examples of what this paper accomplishes.
Although characterized as a chronic disease for more than 200 years, severe and persistent alcohol and other drug (AOD) problems have been treated primarily in self-contained, acute episodes of care. Recent calls for a shift from this acute treatment model to a sustained recovery management model will require rethinking….
There is growing disillusionment with this acute care model of intervention, and rising interest in the stages and processes of long term addiction recovery. This confluence may mark an emerging shift from a treatment paradigm to a recovery paradigm in the clinical
management of severe and enduring AOD problems.
In 1879, Dr. T.D. Crothers, editor of the Journal of Inebriety, typified comparison of addiction to other chronic medical disorders during this era:
The permanent cure of inebriates under treatment in asylums will compare favorably in numbers with that of any other disease of the nervous system which is more or less chronic before the treatment is commenced.
The disease concept fell out of favor in the early decades of the twentieth century. A wave of therapeutic pessimism and new alcohol and other drug prohibition laws led to a collapse of most treatment institutions…
In spite of the recent challenges, the long tradition of depicting addiction as a chronic, relapsing disease continues. Treatment practices, however, continue to be designed and delivered in self-contained, acute episodes of care (Ethridge, et al, 1995). Historically, professionals assess and admit a patient to a course of inpatient or outpatient treatment, discharge that patient to aftercare, and then evaluate whether treatment “worked” by measuring the effect of this single episode of care upon the patient’s post-treatment alcohol/drug consumption and psychosocial adjustment over a brief follow-up period. Such a model of intervention assumes an intervention process whose beginning, middle and end can be plotted over a brief period of time, not unlike interventions used to treat acute trauma, appendicitis, or a bacterial infection.
When Synanon, the first ex-addict directed therapeutic community, encountered a high relapse rate among its first graduates, it shifted its goal of returning rehabilitated addicts to the larger community and replaced that goal with the creation of an alternative drug free community where one could live forever (Mitchell, Mitchell and Ofshe, 1980). Methadone maintenance, as pioneered by Dole and Nyswander, reflected a medically-directed model of long term addiction recovery management (Dole, 1988, 1997).
What these quite different approaches share in common is that they were all severely criticized for their longer vision of recovery management. Mutual aid groups have been (and continue to be) criticized for shifting the addict=s dependency on a drug to prolonged dependency on the support group, Synanon was criticized for its failure to return addicts to the larger community, and methadone was criticized for the very aspects that exemplified the chronic disease management model: prolonged maintenance of narcotic addicts on a stabilizing, opiate agonist and sustained psychosocial supports.
If one were searching for a pivotal breakthrough of consciousness about the distinction between acute and chronic models of addiction disease intervention, it might very well be found in George Vaillant’s 1983 work, The Natural History of Alcoholism. Vaillant’s longitudinal study of alcoholism and recovery challenged three historical assumptions about the disorder and its treatment: 1) alcoholism can be effectively treated with a single episode of acute care, 2) a treatment episode that is followed by relapse is a failure, and 3) repeated relapses following multiple episodes of acute treatment mean that either the condition or the particular patient is untreatable (Vaillant, 1983). Vaillant’s overall work was so pregnant with new ideas that his challenge of these basic premises was lost.
The “treatment careers” research conducted at the University of California’s Drug Abuse Research Center underscores several key points in this emerging view: A single, acute intervention rarely has sufficient effect to initiate stable and enduring recovery in those with severe and persistent alcohol and other drug problems; Multiple episodes of treatment may be viewed not as failures but as incremental steps in the developmental process of recovery; Treatment episodes may have effects that are cumulative (Hser, et al, 1997).
Recovery Review 