What 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.
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.
The 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