The Substance Use Recovery Continuum
Share
In the changing substance use disorder (SUD) treatment and recovery landscape, it can be unclear to individuals and family members just how to navigate within our currently siloed systems. It seems that prevention, harm reduction, treatment, and recovery are all disconnected, and if this is true, how can people navigate this confusing array of options to make an informed decision? It is imperative for individuals seeking help to make informed choices that meet their needs from whatever standpoint they come from. It is almost like you need a map to navigate this system!
With this dilemma in mind, several organizations came together to help develop a recovery map that aligns options based on individuals’ stages of change. Initially, the thought was to create distinctive phases where individuals could self-identify where they should seek services and support. However, given the multiple needs of people seeking treatment and recovery support, and the often changing and dynamic situations people experience, it became evident that it would be more appropriate to utilize the transtheoretical model (TTM) stages of change (Prochaska & DiClemente, 1983) as a basis to develop a meaningful self-identification tool (e.g., a map).
The stages of change is an integrated model for conceptualizing intentional behavioral change often used in describing differences in behavior related to addictive behaviors, which originates from a study on smoking cessation by Carlo DiClemente, PhD, and James Prochaska, PhD (1983). The TTM stages of change are precontemplation, contemplation, preparation, action, maintenance, and relapse. With stages accurately reflected, showing what patients experience in each category, and tied to multiple, widely applicable avenues where patients can seek treatment and recovery, the concept of pairing people for support becomes larger than the sum of its parts. This places individuals at the center of their care—a key ingredient of successful, long-term disease reduction.
The stages of recovery, alongside the stages of change, make up broader categories of recovery exploration, recovery building, and recovery sustaining in the substance use recovery continuum (see Figure 1 below). Recovery journeys are rarely linear and often split into various forks and roads, resulting in reasonably diverse encounters with the health system. These phases are applied to the unique roads individuals encounter on their journeys—entering inpatient care, participating in outpatient services, attempting periods of abstinence, engaging in recovery residence housing, or any combination thereof—and are not necessarily steps necessary for disease maintenance. These phases show that SUD patient journeys require a chronic disease model of care that must include phrases like “maintenance” and “relapse,” indicating that these journeys require continuous work in building and maintaining recovery capital.
With these concepts in mind, a wide-reaching group of various entities from every corner of the SUD community were consulted for first-person thoughts on the patient journey. Drawing upon these experiences through focus group interviews with representatives from California Coalition of Addiction Recovery Advocates (CCARA) patient advocacy organizations and California Consortium of Addiction Programs and Professionals program members resulted in obtaining an accurate picture of experiences on the ground. These representatives are all intimately familiar with the patient journey and have continued involvement in the patient experience as valued advocates, representing the voices of those who are currently undergoing their own journeys. There were a total of thirty-eight interviewees, including individuals in recovery from opioids, stimulants, and benzodiazepines. CCARA is a coalition of thirteen organizations:
- Addiction Recovery Communities of California
- A New Path/Moms United to End the War on Drugs
- CCAPP
- Faces and Voices of Recovery
- Many Paths One Destination
- National Alliance of Medication-Assisted Recovery
- National Alliance of Recovery Residences
- Orange County Recovery Collaboration
- The Phoenix
- The Purpose of Recovery
- Shatterproof
- SMART Recovery
- Young People in Recovery
These organizations are vocal patient advocates that have represented the interest of individuals in recovery statewide and nationally. The focus group interviews occurred during online meetings where representatives from each organization were asked what they thought encouraged patients and deterred patients at each phase of the patient journey. This led to a discussion in the group at each phase of the different experiences with the health care system and what they thought were pain points in the patient journey.
This input was then organized under each phase, refined to be more concise and free of redundancies, and then used as the basis for producing the “Destination Change: A Journey of Recovery” patient map (see Figure 2). To connect individuals viewing the map to the concepts of stages of change and stages of recovery, the project utilizes an evidence-based toolkit: the R1 Recovery Discovery Cards produced by R1 Recovery. The R1 Recovery Discovery Cards are evidence-based assessment tools commonly used to spark meaningful insight and self-discovery from individuals struggling with addiction. The Cards are made up of statements that reflect feelings, emotions, and thoughts individuals on their recovery journey may feel. Card statements that best reflected input from the focus groups were selected for each phase on the patient map. These statements widened the breadth of connection individuals viewing the map may feel and created good benchmarks for characterizing each phase and relating it to the formation of recovery capital.
According to a previous article in Counselor by William White, MA, and recovery capital originator William Cloud, PhD, recovery capital refers to “the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery” from SUDs (2008). White’s work heightened the importance of recovery capital by highlighting the idea that therapeutic processes in addiction treatment must encompass more than a strictly clinical intervention. Strategies that target family and community recovery capital can elevate long-term recovery outcomes as well as the quality of life of individuals and families in long-term recovery.
An article by Best, Vanderplasschen, and Nisic states:
. . . recovery capital can be split into three domains of assets: personal recovery capital, referring to the skills and capabilities the person possesses; social recovery capital, referring to the strength of associations to positive social networks; and community recovery capital, referring to the availability and accessibility of resources such as jobs and houses in the local community (2020).
The framework of recovery capital continues to evolve today, highlighting the idea that, according to the Recovery Research Institute (n.d.), there are multiple avenues to recovery, including the following:
- Clinical pathways: recovery processes aided by the services of health care providers, clinicians, or other credentialed professionals
- Nonclinical pathways: recovery processes that do not involve trained clinicians, but are often community based and utilize peer support
- Self-management pathways: recovery processes that involve no formal services, sometimes referred to as “natural recovery”
In order to maximize the recovery experience, it is necessary for one to adopt a recovery capital approach. The “port of entry” for building recovery capital is crucial to an evaluation of one’s current recovery capital. To raise recovery capital another key “port of entry” is investing in the recovery sustaining category where one coordinates continuing care as an ongoing evaluation of recovery capital needs. Giving people in all stages of treatment and recovery an opportunity to see themselves on their journey is a powerful way to link recovery capital inventory to action. It is also a way for practitioners and those in the wider health care arena to better understand where individuals are in their journeys and to meet them there.
References
- Best, D., Vanderplasschen, W., & Nisic, M. (2020). Measuring capital in active addiction and recovery: The development of the strengths and barriers recovery scale (SABRS). Substance Abuse Treatment, Prevention, and Policy, 15, 40.
- Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–5.
- Recovery Research Institute. (n.d.). Pathways to recovery. Retrieved from https://www.recoveryanswers.org/recovery-101/pathways-to-recovery/.
- White, W. L., & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22–7.
Pete Nielsen is the President and Chief Executive Officer for the California Consortium of Addiction Programs and Professionals (CCAPP), CCAPP Credentialing, CCAPP Education Institute and the Behavioral Health Association of Providers (BHAP), and Publisher of Counselor Magazine
CCAPP is the largest statewide consortium of addiction programs and professionals, and the only one representing all modalities of substance use disorder treatment programs. BHAP is the leading and unifying voice of addiction-focused treatment programs nationally.
Mr. Nielsen has worked in the substance use disorders field for 20 years. In addition to association management, he brings to the table experience as an interventionist, family recovery specialist, counselor, administrator, and educator, with positions including campus director, academic dean, and instructor.
Mr. Nielsen is the secretary of the International Certification and Reciprocity Consortium, and the publisher for Counselor magazine. He is a nationally known speaker and writer published in numerous industry-specific magazines. Mr. Nielsen holds a Master of Arts in counseling psychology and a Bachelor of Science in business management.
Current Issue
Counselor Magazine is the official publication of the California Association of Addiction Programs and Professionals (CCAPP). Counselor offers online continuing education, article archives, subscription deals, and article submission guidelines. It has been serving the addiction field for more than thirty years.
For more information on CCAPP’s many programs, certifications, and career paths, please visit ccapp.us.