DEVELOPING PERSONAL AND SOCIAL RECOVERY CAPITAL IN AND OUT OF TREATMENT

Associate Professor David Best Turning Point Alcohol and Drug Centre

1. What is the recovery model and why tied to strengths and communities?

MENTAL HEALTH RECOVERY MODEL – Leamy et al (2011)

CONNECTEDNESS HOPE IDENTITY MEANING EMPOWERMENT

Recovery precursors – RETHINK (2008)

Safe place to live Basic management of physical and

psychiatric distress Basic human rights and choices

Recovery time course Alcohol 4-5 years Opiates 5-7 years

Why do people recover? Moos (2011)

MODEL MEANING

1. Social control Bonding and support; goal direction (from family, friends, etc); structure and monitoring

2. Social learning Observation and imitation of family, peers and mentors; learning positive and negative consequences

3. Stress and coping Building self-efficacy and self-confidence; developing effective coping skills

4. Behavioural economics

Involvement in protective activities – alternative rewarding activities

Do people get better?Calabria et al (2010)

Systematic review of remission papers between 1990 and 2009

“Almost one quarter of persons dependent on amphetamine, one in five dependent on cocaine, 15% of those dependent on heroin and one in ten dependent on cannabis may remit from active drug dependence in a year” (P747-748)

“The estimates suggest that persons who meet criteria for drug dependence at a given point in time have a relatively high chance of remitting within a short time frame” (P747)

WHAT IS RECOVERY CAPITAL?

Granfield and Cloud (2008) define recovery capital as

“the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from AOD [alcohol and other drug] problems”.

White and Cloud (2008): Stable recovery best predicted on the basis of recovery assets not pathologies

Definitions of social capital

The sum of resources, virtual or actual, that accrue to a group through possessing a durable network of relationships (Bourdieu)

Features of social organisation such as networks, norms and social trust (Putnam)

A culture of trust and tolerance in which extensive networks of voluntary associations emerge (Inglehart)

Capacity of individuals to command scarce resources by virtue of their membership in networks (Portes)

Indicators of social capital Orford (2008)

General trust in others Feeling of belonging to the area Relations with neighbours Feeling safe / trust in the police / low crime

rate Existence of and participation in social

networks Low migrating out rates Social pro-activity / helping others

Forms of social capital Szreter and Woolcock (2004)

1. Bonding: trusting and cooperative relationships between members of a network who share an aspect of social identity

2. Bridging: relations of respect and mutuality between people who know they are not alike in some respect

3. Linking: norms of respect and development of trusting relationships between people interacting across explicit formal or institutionalised power barriers

Ziersch’s (2005) model of social capital

SOCIAL CAPITAL INFRASTRUCTURE

Cognitive: Trust, reciprocity

Structural: Formal networks,

informal networks

SOCIAL CAPITAL RESOURCES

Social support Social cohesion Civic activities

Elements and dimensions of community identity (Orford, 2008)

Residents’ perceptions of the distinctiveness of their community Residents’ perceptions of the special character of the community Residents’ perceptions of their own affiliation or belonging Residents’ perceptions of others’ affiliation or belonging Residents’ reasons for their identification Residents’ orientation to the community (personal investment,

attraction, safety) Residents’ evaluation of the quality of community life Residents’ perception of others’ evaluation of the quality of

community life (community spirit, friendliness, cooperation) Evaluation of community functioning (community services,

leisure services, health services, opportunity, material quality of life, quality of the environment)

Collective efficacySampson (2008)

Defined as: clear norms, a high level of mutual trust, low level of fear and a willingness to share

Based on data showing the impact of neighbourhood on criminality and mental health in adolescents

Directly linked to community resources – childcare, education, recreation, health, employment, opportunity and stability of the resident population

Best and Laudet (2010)

Social Recovery Capital

Collective Recovery Capital

Personal Recovery Capital

Mapping the recovery journeys of former drinkers in recovery – Hibbert and Best (2011, Drug and Alcohol Review)

“The Power of Recovery”(Personal communication with Phillip Valentine, Executive Director, CCAR, Connecticut Community for Addiction Recovery)

Time

Pote

nti

al

“Normal People”

“Recovering People”

“Long Term Recovery”

“Better than well”

“A grateful addict/alcoholic”

“Model citizens”

“Early Recovery”

“5 years+

In recovery”

2. Is treatment enough? The professional problem

Desistance rates

CSAT (2009): 58% of life-course dependent users of substances will achieve lasting recovery

Welsh workers’ estimate: 7%

Time spent (in minutes) in last drug working session (Best et al, 2009)

How time is spent

13.7

11.710.6

10.6

Case Management Links to other servicesTherapeutic Activity Other

UK treatment activity Clients seen typically

between 1-2 times per month

10 minutes on psychosocial interventions

Karpusheff et al (2012): Sandwell – once every 4.4 weeks for 31 minutes

Wisely et al (2011): Salford – 30 minutes monthly

Best et al (in press)

Measuring wellbeing by abstinence, activity and safe housing in Sandwell – treatment populations

Baseline Follow-up8

9

10

11

12

13

14

15

16

17

0 recovery enablers

1 recovery enabler

2 recovery enablers

3 recovery enablers

5-26 weeks 27-52 weeks 1-3 years 3+ years0

2

4

6

8

10

12

14

16

18

13.2955 13.4060 13.445812.9478

Differences in reported quality of life as a function of outcomes achieved

.00 1.00 2.00 Linear (2.00) 3.00

Is the ‘treatment system’ good enough? ‘Careless Society’ – John McKnight

“The professional problem” – the iatrogenic and self-serving agenda of professionals

“Increasingly, professionals are claiming the power to decide whether their ‘help’ is effective. The important, valued, and evaluated outcome of services is the professional’s assessment of their own efficacy. The client is viewed as a deficient person, unable to know whether he has been helped” (McKnight, 1995, p.50)

The ultimate aim of professionalisation

We are the solution to your problem We know what problem you have You cant understand the problem or the

solution Only we can decide whether the

solution has dealt with your problem

The value of chronic illness

“A person with a perilous and extended illness (a health consumer) contributes significantly to our economic growth by using large amounts of the commodities produced by our health system. Indeed, a very ill person disabled for a considerable amount of time could cause production of much more medical dollar value through their illness than the value of their own production were they healthy” (McKnight, 1995, p.162)

The consequence of professionalisation

1984 study by Community Services Society of New York

Approximately $7,000 per capita of public and private money is allocated to the low income population of that city

37% of this money reaches low income people in cash income

Nearly two-thirds is consumed by those who service the poor

3. The power of community and connectedness

Social networks and quality of life

Holt-Lunstad et al (2010): meta-analysis: “individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships” (p.14)

Participation in groups is associated with less psychological distress (Ellaway and MacIntyre, 2007)

Volunteering is associated with reduced mortality (Ayalon, 2008) and higher levels of reported wellbeing (Morrow-Howell et al, 2003)

Helliwell and Barrington-Leigh (2012): the benefits of social capital

Based on the Canadian General Social Survey

Strronger social networks are associated with higher life satisfaction

But this is mediated by more frequent use of the social support network, when there is greater trust of people you live and work with and when people feel a sense of belonging in their communities

Study of workers in the field in recovery from heroin addiction (n=108)

Why did they stop? Tired of lifestyle plus a trigger event – physical, psychological or family based

Why did they stay stopped? Other people Moving away from using networks Finding supportive non-using recovery

networksBest et al (2008)

Litt et al – “Changing network support for drinking” (2009)

186 participants randomised to network support (NS) or case management (CM)

Network support condition resulted in better outcomes than case management

“The addition of just one abstinent person to a social network increased the probability of abstinence for the next year by 27%” (p230)

Social networks can be changed by an intervention that is specifically designed to do so

McKnight and Block (2010): Stronger support networks linked to better access to community resources and to better health

Framingham Heart StudyChristakis and Fowler

A person’s odds of becoming obese increased by 57% if they had a friend who became obese, with a lower risk rate for friends of friends, lower again at three degrees of separation

No discernible effect at further levels of remove Smoking cessation by a spouse decreased a person’s

chances of smoking by 67%, while smoking cessation by a friend decreased the chances by 36%. The average risk of smoking at one degree of separation (i.e., smoking by a friend) was 61% higher, 29% higher at two degrees of separation and 11% higher at three degrees of separation.

Node = a person

Line = a relationship between two people

“embedded”: the degree to which a person is connected within a network

more embedded = central

less embedded = periphery

Terms• Contagion: what flows across ties (germs, money, violence, fashions, organs, happiness, obesity, etc.)• Connection:

who is connected to whom (ties to family, friends, co-workers, etc.)• Homophily:

the tendency to associate with people who resemble ourselves

(“love of being alike”)

The Obesity “Epidemic”

Your Friends’ Friends Can Make You Fat

Photos by Colin Rose and Sherrie G

The Obesity “Epidemic”

• 66% of Americans are overweight or obese• From 1990 to 2000, the percentage of obese people in the USA increased from 21% to 33%

1975 1990

Green Node: nonobeseYellow Node= obese (size of circle is proportional to BMI)

TRADITIONAL SCOTTISH LUNCH

BRIDGE WALK TO RECOVERY, MELBOURNE 15.4.2012

VISIBILITY OR NOT – STUDY OF HIV POSITIVE GAY MEN

Cole et al (1996): study of the long-term effects of hiding their sexual identity: associated with higher rates of cancer and infectious disease

Jones et al (2012): Those who hide a potentially stigmatising condition more vulnerable to the negative views that mainstream society holds because it limits their ability to develop a collective coping response

Molero et al (2011): while there were risks, disclosing their HIV status allowed individuals to develop a sense of shared identification with others in the same situation

VISIBILITY OR NOT

Beals et al (2009): Among gay men and lesbians: voluntarily mentioning one’s sexual orientation to others when the opportunity presented itself was associated with lower levels of depression and higher levels of self-esteem

This relationship was mediated by perceived levels of social support

VISIBILITY OR NOT - ABI

Molero et al (2011): Concealment of injury may be an important strategy for protecting oneself from negative outcomes

However, respondents who were more willing to disclose their injury to others reported higher levels of self-esteem and life satisfaction

4. And the importance of doing things

Social and mental health benefits of choir singing for disadvantaged adults

Reclink community choir engagement at baseline, 6 and 12 months -21 IPA interviews

PERSONAL IMPACT: positive emotions, emotion regulation, spiritual impact, identity

SOCIAL IMPACT: connectedness with choir, with audience, with community

FUNCTIONAL IMPACT: health, employment capacity, routine and structure

Dingle, Brander, Ballantyne & Baker (2012)

Dingle et al (2012): Personal, social and functional growth

Douglas (2012): intensive social support for individuals with Traumatic Brain Injury (2012)

Programme over 6 months – sports, arts, cooking

Naturalistic split into completers, partial engagers and non-participants

Sustained group better at 6 months in Social integration Mental health Quality of life Reduced depression

Recovery studies in Birmingham and Glasgow (Best et al, 2011a; Best et al, 2011b)

More time spent with other people in recovery

More time in the last week spent: Childcare Engaging in community groups Volunteering Education or training Employment

Comparison of US data with 113 participants recruited from Melbourne

NEW YORK MELBOURNE

Age 44.1 yrs 43.2 yrs

Duration of abstinence

45 months 72 months

Lifetime MH diagnosis 38.5% 63.2%

HIV+ 26.7% 1.0%

HCV 31.2% 41.3%

Primary heroin 21.8% 41.6%

Primary crack 59.2% 0.9%

Current 12-step 79.7% 69.3%

Current social club/group

13.7% 40.7%

Employed FT 48.4% 58.3%

Currently in education 21.7% 31.9%

Victorian reform – recovery

Recovery-oriented treatment in Victoria

‘Recovery’ is individually definedStrengths and hope basedConnects people with other services they needRecognises and builds support pathway beyond treatmentTreatment delivery that respects and supports individual goals Involves and engages people in planning and decision makingRecognises, encourages and supports family/carer involvementLanguage, attitudes and behaviours that are respectful of, and hopeful for, the client’s goals

New models of care – 6 core service types

Education, Information, Intake• Teleph

one helplines

• Web-based tools

• Regional intake

• PAMS• DACA

S• AMS• ABI/

DD

Assessment Care and Recovery Co-ordination• CCCCs• ADSA• ACSO

COATS• Koori

A&D Workers

• Outreach

• Peer support

• Post Resi workers

• ABI/DD

• MORS

Counselling• Day

programs

• CCCCs• Thera

peutic 4Cs

• Parenting support

• Family counselling

Withdrawal• Reside

ntial• Home

based• Outpa

tient• Rural• CHAD

Pharmaco-therapy• GPs

and pharmacists

• SPS• PRO

W• WAD

S

Residential Treatment• Reside

ntial rehabilitation

• Therapeutic communities

• Short-stay rehab

5. And finally the measurement of recovery capital

Groshkova et al (in press) Drug and Alcohol Review

50 item strengths based scale 10 dimensions Capacity to differentiate between in and

out of treatment populations Use as a care planning tool Equally relevant to those in and out of

treatment

Background

The recovery movement is about some key principles:

Empowerment of the service user Involvement of their family, and developing

community and peer supports Dynamism that helps clients move forwards with

their lives and that the focus is not all about the substance

Recovery is a journey in which treatment plays an important role in engaging and motivating clients

Aim of the model

To create a ready reckoner that will assess the five key stages of treatment recovery journeys:

1. Motivation to recover2. Engagement in the treatment and recovery

process3. Development of personal recovery capital4. Development of social recovery capital5. Engagement in recovery communities

CEST - MOTIVATION

There are 2 measures of motivation

1.) Readiness to change 2.) Desire for help

• Participants reported a mean total motivation score of 12 (on a scale of 0-14)

• For the overall scale that is recalculated to a score out of 20 – and so mean = 17.1/20

CEST – TREATMENT ENGAGEMENT

There are 3 measures of treatment engagement

1.) Counsellor rapport 2.) Treatment Satisfaction 3.) Treatment Engagement

• Participants reported a mean total treatment engagement score of 12.3 (on a scale of 0-32)

• Again this is recoded to a score out of 20 = 7.7.

ARC -Personal Recovery Capital

Personal recovery capital is made up of the following 5 subscales:

- 1.) Psychological health- 2.) Physical health- 3.) Risk taking behaviour- 4.) Coping & life functioning- 5.) Recovery experience

• Participants reported a mean total personal strengths score of 13.8 (on a scale of 0-25).

• When recoded to a score out of 20, this gives a mean score of 11.0

ARC – Social & Lifestyle Recovery Capital

Social & lifestyle recovery capital is made up of the following 5 subscales:

- 1.) Substance use & sobriety- 2.) Citizenship- 3.) Social support- 4.) Meaningful activity- 5.) Housing & safety

• Participants reported a mean total social & lifestyle strengths score of 12.7 (on a scale of 0-25), recoded to a mean score of 10.2 .

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12

34

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23

45

11

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PHASE 1

PHASE 2

PHASE 3

TREATMENT ENGAGEMENT

TREATMENT MOTIVATION

PERSONALRECOVERYCAPITAL

SOCIALRECOVERYCAPITAL

RECOVERYGROUPCAPITAL

THANK YOU

Associate Professor David Best davidb@turningpoint.org.au David.best@monash.edu