What is recovery and how do we measure it?

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ResearchBlogging.orgWhat is recovery and how do we measure it? It’s a contentious issue. One problem with asking services to deliver recovery outcomes is that we actually do need to measure something to see if taxpayers are getting value for money. In a recently published paper, John F Kelly and Bettina Hoeppner from Harvard, take a look at the problems inherent in trying to define and measure recovery and make a suggestion for a different way of framing it all.

They start by looking at how recovery is unfolding as an organising paradigm, resulting in the birth of a recovery movement and altering policy in various countries including the UK as a whole and in Scotland.

The paper lays out six definitions side by side including the Scottish Government definition from 2008. Most of the definitions mention improved health, four detail abstinence, and three also suggest citizenship as important. Kelly and Hoeppner present some of the challenges around the last of these – how many of the general population contribute actively to local communities for instance?

Ultimately, of course, it rests on the individual to decide if he or she is in recovery. As Phil Valentine has said: “You are in recovery if you say you are.” That doesn’t solve the problem of how commissioners decide when a service is delivering on recovery, so the authors advocate putting on a new pair of metaphorical specs.


Box 1 (After Kelly & Hoeppner, 2014)

What the authors suggest is taking a double pronged approach, or in scientific terms, a “biaxial formulation”. This has been done before by other researchers, notably Edwards and Gross who, working on ‘removal of negatives’ model set addiction along one axis, with all the negative consequences along the other access. (See top graph in Box 1)

Kelly and Hoeppner suggest a more assets based approach, which is after White and Cloud (and if I’m not mistaken, Laudet and Best). In this formulation, recovery capital (the resources that can be drawn on to assist recovery) is charted against addiction remission. The authors explain:

Clearly, the prognosis for addiction recovery is not just a function of the severity of the illness, but also a function of resources that one can bring to bear in aid of the recovery attempt.

The paper lays this out in the context of the Transaction Model of Stress and Coping; something that the neuroscience of addiction and recovery supports. We know people are more likely to relapse when stressed. And isn’t early recovery a stressful process? Stress hormones do run higher in recovering people at this time. High levels of circulating stress hormones can interfere with the ability to learn new things and may make individuals vulnerable to stress-induced relapse. So what’s the solution? Recovery capital:

Greater availability and accrual of recovery capital will influence resilience and coping, and help reduce and buffer stress, including serum cortisol levels, supporting continued remission. Conceptually, then, the appraisal of, and coping with, the stressors encountered in recovery will co-vary along with the degree of available recovery capital.

Recovery-ManThe idea is that greater accrual of recovery capital is likely to result in higher levels of remission from addiction. This, of course is not new, but setting it in a stress model clarifies what recovery capital can influence. They keep the definition of remission loose here, it does not necessarily relate to abstinence, thus making recovery less exclusive. The model is representational; the authors don’t suggest a purely linear relationship here, but it is a helpful outline.

The authors finish with yet another definition of recovery:

‘‘Recovery is a dynamic process characterized by increasingly stable remission resulting in and supported by increased recovery capital and enhanced quality of life’’

Why do we need another definition? Here’s why they think it might be useful:

First, it highlights the dynamic nature of recovery. The word ‘‘process’’ captures this aspect too, but adding the word ‘‘dynamic’’ emphasizes the variable nature of the terrain encountered on the varied paths to recovery. Second, it describes the substance use dimension as being in ‘‘remission’’ which is not synonymous with abstinence or sobriety (i.e. ‘‘remission’’ suggests that one could be using substances and exhibit improved functioning at a sub threshold level).

As such, it caters to those that may be using in a non-symptomatic manner which may foster greater sub-cultural or international and cross-cultural utility (e.g. in the UK). As noted, most importantly, it separates increasingly stable remission from the disorder itself, from the important resulting accrual of recovery capital and evokes a reciprocal aspect whereby increasing remission enhances recovery capital and vice versa.

I can see conceptual problems in the UK around those using drugs (with little harm) being defined as ‘in recovery’, but I get the point. What the authors want to stimulate is debate and what that debate will need to generate is some meat to put on the bones of the paradigm. What do commissioners get services to measure? (Accruing recovery capital and evidence of remission, presumably) What tools do we use and in what way is that different to what we are currently doing at the moment?

Kelly, J., & Hoeppner, B. (2014). A biaxial formulation of the recovery construct Addiction Research & Theory, 1-5 DOI: 10.3109/16066359.2014.930132

    3 Responses to "What is recovery and how do we measure it?"
    1. Vicky S says:

      Really good and interesting read yet again! My argument has always been how recovery can even be measured if it is not clearly defined. Services and commissioners each have their own definition but without an agreement then it proves impossible to measure something that isn’t even defined. Thanks for sharing a really thought-provoking article.

      • djmac says:

        it’s a tough one, but I guess you can measure recovery proxies. If we stick with individual items representing recovery capital, then we could measure improvements in mental and physical health, in the quality of relationships, in moving out of crime, of having meaningful scheduled activity, of volunteering, of education, of employment, of moving off benefits etc. Other useful measurements might be made of connections to recovery communities and the resources therein.

        Thanks for the positive feedback.

    2. It would be wonderful thing if everyone involved in helping addiction sufferers get well were interested in the question: How do you measure recovery? Unfortunately, there are very few. And even of those that want to or are attempting to, they are using antiquated methods and as you greatly point out, cannot agree on a definition of recovery.

      What really turned my head about this post was your pinpointing of “recovery capital” as a possible measure. What’s interesting about your revelation (and as I state below — ours), is that many in addiction treatment and recovery (in the U.S.) are well aware of White and Cloud’s notion of recovery capital, but most have simply ignored it. My assumption for why recovery capital as an outcome measure is being ignored is because the funders of agencies in the U.S., largely state and federal governments, have their own [antiquated] outcomes that must be tracked and measured. And, because funding is so scarce and seems to get smaller every year, there is no room for trying something different and for innovating.

      That said, let me tell you that there is one organization in the U.S. that has embraced the notion of Recovery Capital and we’ve done it in a very exciting way. First, who am I and who am I with. I am the Addiction Informatics Officer for Face It TOGETHER (www.wefaceittogether.org). We are a national not-for-profit with the vision of solving the disease of drug and alcohol addiction. We are a team of social entrepreneurs who are applying private-sector know how to solve a social challenge. We have local affiliate organizations (www.faceitsiouxfalls.org) that deliver FREE recovery support services that both help individuals and families navigate to treatment and other services, and provide sustaining support to keep people well. Our local affiliates are all financially sustainable, neither seeking nor receiving funds from state or federal government; instead, we partner with employers, health care, and others, all of whom “invest” in our organization for the value that we deliver.

      All that said, we therefore are beholden to do things differently — especially measure outcomes. Until recently, we have measured our effectiveness using the antiquated measures all addiction treatment and recovery agencies use: substance use / frequency; employment; and/or housing. In 2013, we served more than 2,600 people in Sioux Falls, SD. Of those that utilized Telephone Recovery Support, 83% were “in recovery” (self-report to have remained abstinent) after one year. Of those that utilized a Recovery Coach, 62% were “in recovery” after one year. Our outcomes are off the charts, despite an unbelievably fragmented addiction information and treatment system in Sioux Falls (as it is everywhere).

      Although our outcomes are good, these outcomes do not tell us how “well” our clients are, nor do they tell us whether our partners have earned a return on their investment. Also, these outcomes say nothing about the economic and social impact to the community of having more people “in recovery.” This is more than simply agreeing on a definition a recovery. Face It TOGETHER choses the ASAM and the SAMHSA definitions which are differently stated but very similar in that they both see recovery as a process toward wellness.

      So, let’s take our measures beyond the measurement of use/non-use and measure something more — that which either helps or hinders a persons recovery and/or wellness — Recovery Capital.

      Bill White is a great friend to Face It TOGETHER and is aware of what we call the Recovery Capital Index™ (RCI). Essentially, what we have done, is taken his notion of Recovery Capital, the concept that is, and structured a set of surveys into the three key domains: Personal Recovery Capital, Family/Social Recovery Capital, and Cultural Recovery Capital (White and Cloud discuss community recovery capital, but we are developing a separate measurement for community recovery capital). Within each of those domains, there are a set of defined components. And, within the components are sub-components — wherein there are specific survey scales. There are 19 total scales, each having about 3-6 questions, all of which are from reliable and validated survey tools elsewhere. We’ve applied a proprietary algorithm which then calculates a sub-component score, then a component score, then a domain score, then ultimately a Recovery Capital Index™.

      See a graphical representation of the RCI here: http://www.wefaceittogether.org/what-we-do/population-health-management

      Earlier this year, our local affiliate organization began surveying our clients with the RCI. At the same time, we have been developing a database that will allow us and our clients to engage with the RCI in a real-time basis. Because the RCI is more than just a “survey” but intended to be a frequently used measurement tool (especially in during first year — 4 survey points), we can do and learn much more from the data. In fact, we are building a web-based portal where our clients will be able to connect with their recovery coach and also engage with their RCI and take/update portions of the RCI at their (or their recovery coaches) choosing. Therefore, the RCI now becomes a cognitive behavioral tool.

      What will this tell us about recovery? Hopefully a lot. We expect it will help our clients understand what areas they need more work via a quantifiable representation of their total wellness. When coupled with the individual’s electronic health record, know their care providers can get real smart on how to provide better, more customized care for that patient. It truly is a new world.

      Thank you for your blog… I’ve become a regular reader.

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