Understanding More About Abstinence Focused Recovery Communities

1. OVERVIEW

1a. Government’s current drug and alcohol strategies and direction of travel:

In 2008, the UK Government launched a new drug strategy that signalled a significant change in approach from a model primarily based on harm and risk reduction to one focusing on communities, families and personal wellbeing, with a commitment to a recovery model that has achieved considerable currency and success in the mental health field (Leamy et al, 2011). This commitment has been further enhanced by the Home Office publication “Putting Recovery First” (Home Office, 2012) which went further in specifying the idea of ‘full recovery’ based on a commitment to abstinence as the primary aim of a recovery model. This is entirely consistent with the findings of one research study by one of the authors (Best et al, 2011) of clients in treatment in Birmingham where those who were abstinent showed significantly higher quality of life. Likewise, in a review of treatment outcome data from two English DAAT areas (Best et al, 2012), there were two main predictors of quality of life and wellbeing – engagement in meaningful activities and abstinence from heroin and crack. What is more, in a change analysis in this study, clients who became abstinent in the course of the study reported significant improvements in their quality of life and physical and psychological wellbeing, while those who started using again showed equivalent reductions in these areas.

1b. What is meant by a recovery community and what should it look like?

As important as the changing role of professionals and the empowerment of the person in recovery, is the increased role of communities as both a setting for recovery to occur in and a foundation for supportive relationships and opportunities for vocational and personal growth, as well as a developmental platform for recovery. There is a growing focus on the ‘ecology of addiction recovery’ – how the relationships between individuals and their physical, social, and cultural environments promote or inhibit the long-term resolution of substance problems. There is also an increasing acceptance that recovery is an intrinsically social process (Best, 2012) with fundamental implications for not only movement away from using communities but active engagement with individuals and groups who support recovery (Best et al, 2008). According to this model (Moos, 2007) individuals learn to recover by copying the behaviours of attractive role models and being constrained and shaped by participation in the norms, rules and values of recovery groups and communities.

Christakis and Fowler (2010) and Best (2011) have shown that the likelihood of behaviour change can be significantly increased by the nature of an individual’s social networks and the number and strengths of the resultant links. Litt et al (2007) concluded that the addition of one abstinent friend to a network increased the chances of abstinence by 27% among individuals who had recently completed residential alcohol detoxification. Indeed, in their conclusions to the large US outcome study, Project MATCH, Longabaugh and colleagues (2010) concluded that one of the key predictors of effective recovery was the transition from a social network that supports drinking to a social network that supports recovery.
At its broadest, this is the essence of a recovery community. The growth of associations, community champions and recovery-oriented institutions in communities creates a social learning foundation for what can be the ‘contagion’ of recovery in local communities and increases both the visibility and viability of recovery communities. In social capital terms (Putnam, 2000) it is the increase in the density of recovery nodes and the bridges between them that increases the availability and influence of recovery communities.

It may occur online or in person, it may be structured and organized or it may involve informal and personal support, but the recovery community is the networking and affiliation of individuals to support themselves and each other in their recovery journey. According to White’s work on Peer Based Recovery Support Services (PBRSS, White, 2009), recovery communities should operate to high ethical and governance standards, be effectively networked with both formal treatment and community services, have strong links to the existing community and be active in its promotion and support of recovery.

There is no consensual, evidence-based model of what a recovery community should look like in the UK. It should certainly build on existing assets – our work in York (Best et al, in press) is based on this idea of identifying existing community resources and community connectors and using them to create bonding and bridging social capital is crucial to this idea of recovery as a locally owned and determined form of co-determination, where professionals have a key but subsidiary role. Our seminal work in Barnsley (Best et al, 2013) brought together a range of community groups and resources, mutual aid groups, people in recovery, professional staff and commissioners to form a Barnsley Recovery Coalition who have gone on to have a recovery walk, a sports day an art walk and a range of other events. In this sense, the Recovery Coalition was a meta-recovery community that provided a coalition of recovery approaches and brought them together with a common aim of supporting diversity in recovery, providing routes to hope, and a visible sense of recovery community that became a part of the lived community. This is consistent with an Asset-Based Community Development model (ABCD; Kretzmann and McKnight, 1999) where lasting community change is predicated on identifying and mobilizing indigenous resources in the community.

Communities differ in several respects, but also share many common features. Almost all owe their origins, to a greater or lesser extent, to the influence of Alcoholics Anonymous (AA) or to the emergence of a graduate community from a Therapeutic Community, and they all share a common focus of abstinence as the primary driver of recovery. To create kinship and common purpose amongst the recovering community it would appear that the goal of abstinence is imperative. They see recovery from addiction as requiring a profound structuring of thinking, personality, and lifestyle, and involving more than just giving up drug taking behaviour.

1c. What are the barriers to sustaining dependency free recovery and how can recovery communities address these?

The best predictor of the likelihood of sustained recovery is the extent of ‘recovery capital’ or the personal and psychological resources a person has, the social supports that are available to them and the basic foundations of life quality, i.e. a safe place to live, meaningful activities and a role in their community (however this is defined). While structured treatment has a key role to play, it is only part of the support that most people will need. Ongoing support in the community is essential for the ongoing recovery journey and often includes mutual aid and other forms of peer support. In the Glasgow Recovery Study (Best et al, 2011), the two biggest predictors of recovery were meaningful activities and spending time with other people in recovery. In other words, the key barriers to recovery are lack of things to do and lack of a supportive peer network. As Longabaugh and colleagues reported in the context of Project MATCH data (Longabaugh et al, 2012), recovery is most likely when people transition from a network supportive of drinking to a network supportive of recovery, which in the context of this study meant abstinent recovery. Thus, the lack of available recovery role models (Moos, 2007) and transmitters of hope (Leamy et al, 2011) are likely to be community level barriers to recovery in areas where there is limited visible recovery champions or groups.

Relapse is a major risk factor with as many as 50-70% of individuals completing detoxification treatment relapsing within the first year (Dennis et al, 2007). While there is good evidence that aftercare can reduce the likelihood of relapse by as much as 30-40%, it is estimated that only around one in ten individuals completing treatment will get adequate aftercare (White, 2009), thus clear pathways to continuing care is an important predictor of reduced relapse risk (Vanderplaschen et al, 2013). Recovery is more likely to be sustained where individuals have a positive recovery identity (McIntosh and McKeganey, 2000), where individuals are engaged in meaningful activities (Best et al, 2011) and where the individual has a greater sense of hope and active engagement in their community. As Best and Laudet (2010), the need for community capital means that there is a significant risk to people where there are limited recovery-oriented (and abstinence-oriented) treatment services and no adequate links for people completing treatment to recovery housing (Humphreys and Lembke, 2013), jobs and peer- based recovery support groups (Humphreys and Lembke, 2013; White, 2009).

Supportive social networks in recovery communities may enhance social connectedness by provide the opportunity for the sharing of resources, information, social support, and may reinforce behaviours that facilitate recovery, and sustain motivation for change. Furthermore, participation in groups such as recovery groups may foster a sense of meaning and cultivate a positive sense of identity. Having a sense of purpose, social connectedness, and filling time with meaningful activities is not only likely to help prevent relapse but also enhance quality of life, which is a concept that is increasingly being recognised as important in the addictions field (Laudet, 2011).

In a recent study comparing treatment seeking populations in Sweden and the US, Trocchio and colleagues (2013) attempted to investigate the effects of co-morbid mental health problems on participants’ ability to sustain abstinence for a year. While the effects around mental health problems were weak, participants who were employed and had moved away from their using networks were three times more likely to be abstinent in both the US and Sweden.

There is evidence for negative prognostic relationships between social networks supportive of substance use and increased risk for relapse to alcohol use (Longabaugh et al., 1998; Longabaugh, Wirtz, Zywiak, & O’Malley, 2010), and between network change toward decreased support for substance use from pre to post-treatment and reduced risk for relapse to alcohol (Litt, Kadden, Kabela-Cormier, & Petry, 2007; Litt et al., 2009; Longabaugh et al., 1998) and poly substance use (Zywiak et al., 2009). In other words, other people matter in enabling and sustaining recovery, and they can also provide an important role in accessing community capital (Landale and Best, 2012).

Sustaining recovery is likely to involve a complex mix of factors including changes in social network, engagement in recovery support groups and broader life changes including improvements in quality of life, psychological wellbeing and physical health. But there are also internal processes that make a difference. In his summary of the key psychological mechanisms for recovery, Moos (2007) identified four key factors in the recovery process:

  • the growth of personal resources and skills such as self-esteem and self-efficacy. Humphreys and Moos (2005) have argued that engagement in mutual aid (peer support) groups is an important part of developing these skills and resources and more recently, Moos et al (2012) have shown that long-term engagement in mutual aid contributes to reductions in impulsivity over and above those associated with maturation in a 16-year follow-up study.
  • a commitment to the perceived desirability of recovery (which he referred to as behavioural economics)
  • social learning – that people develop recovery skills by observing them in attractive recovery champions and copying them
  • social control – which involves spending time with people and engaged in activities that do not support or encourage active use.

Although there is no point when someone is safe from the risk of relapse, Orford (2000) has estimated that the relapse risk drops to as low as 15% if individuals can make it to five years abstinent. In the Betty Ford definition of recovery (Betty Ford Institute Consensus Group, 2007) this is referred to as ‘stable recovery’ and having a cohort of visible and linked recovery champions who are in this category (more than five years of continuous sobriety) may well be a strong protective factor against elevated relapse risks. One of the massive challenges of a recovery community is to provide people with the supports and resources to help them reach this point.

2. Provision

2a. What is the current scope and scale of recovery communities and what different recovery models exist across the UK?

It is now widely accepted that generally the lack of a visible recovery community, together with ‘fragmented’ pathways in many areas has limited the opportunity for clients to achieve and sustain abstinence – according to Best et al (2008), in a study of recovery pathways among addiction professionals, social networks are rarely the catalyst for recovery but are critical in sustaining them. There is undoubtedly a marked variability across the UK – indeed one of the authors (DB) was involved in a Scottish Government review of treatment which concluded that there had not been sufficient progress in implementing the recovery components of the 2007 strategy “Road to Recovery”. A similar picture pertains in England with marked variability across Drug and Alcohol Action Team areas in recovery progress. One of the authors (DB) has worked on some exceptionally innovative work on developing recovery communities in both Barnsley (Best et al, 2013) and in York (Best et al, in press). The other author (SH) has examined how recovery works at a locality level in 6 areas across England in the last 18 months and in a review of recovery communities for the NTA (Best et al, 2012). These studies are important as there is a range of innovative practice that has not been subjected to sufficiently rigorous academic scrutiny to be endorsed.

There are many (secular, spiritual and religious) pathways to long-term recovery communities across the UK that constitute broad organising/sense-making frameworks for change. The idea that collective endeavour and group processes among those in recovery is inherently therapeutic and that the professional and specialist input less important is nothing new. There are varied styles of recovery within these broad pathways (White & Kurtz, 2006). Styles of recovery encompass variations in:

  • Goals (abstinence versus long-term moderation)
  • Personal identity (recovery positive, recovery neutral, and recovery negative)
  • Degree of affiliation with others in recovery (this will include the extent of
  • social learning and engagement in shared activities, as well as the coherence of views and beliefs about recovery)
  • Type of resources mobilised for recovery support (solo recovery, peer supported recovery, professionally-supported recovery

From the 1980s we have seen the growth of many therapeutic communities in the addictions field across the UK such as Phoenix House, the Ley Community, Emmaeus, Reto, Cenacolo and Betel. These have become iconic models for therapeutic group processes and have been replicated across the world in community settings. One of the problems we have is that – because of the focus (and research funding) on acute interventions and medical maintenance, there is extremely limited evidence about aftercare and ongoing support. However, Vanderplaschen et al (2013) have demonstrated the importance of aftercare in sustaining the benefits of treatment.

It would appear over the last 5-10 years an influential development in the sustainability of vibrant recovery communities has been the growth of relatively short-term, residential ‘Twelve-Step Facilitation’ or ‘Minnesota Model’ programmes. These are generally closely linked to the Twelve Step principles of AA/NA, and typically provide a highly structured package of residential care involving an intensive programme of daily lectures and group meetings designed to implement a recovery plan based upon the Twelve Steps. Once individuals successfully complete such a program of support they are encouraged to link in with the local recovery community and attend mutual aid meetings in the area. Growth of recovery communities of this kind can be seen widely in areas such as Liverpool, Blackburn, Burton, Weston, Bristol, Bournemouth and Plymouth. However, there is insufficient evaluation or outcome research in relation to these projects and initiatives and as Best and colleagues (2010b) concluded in a review of Yorkshire and Humberside services for the NTA, this results in a danger of re- inventing the wheel and regular repetition of the same mistakes. One of the main problems that an evidence base for recovery faces is a lack of evaluation, research and quality standards information.

However, with such limited access to residential rehabilitation opportunities across the UK there is a growing recognition that recovery initiation in such residential settings will not assure sustained recovery maintenance in the community. The importance of ongoing support after structured treatment, the positive outcomes associated with mutual aid and peer support in the community (and the importance of assertive follow-up support) need to be further developed across the country. Limitations of funding have prevented such residential services from providing adequate aftercare or from evaluating what they did provide.

Over recent years there have been some models, which offer intensive therapy (usually 12 steps) within either a supported housing or peer support set up, but based in the client’s local community. The success rate for these is impressive with a very low relapse rate and US research (Humphreys and Lembke, 2013) would suggest that this has a huge benefit in terms of sustaining recovery – in one study, clients assigned to Oxford House accommodation had more than twice the rate of abstinence at 2-years compared to the control condition (65% versus 31%; Jason et al, 2006). The added advantage is that, unlike the traditional model, where people have to move away and ‘re-invent’ themselves in another location, with this model, those who become abstinent stay in the local community and become examples for others to follow. An indigenous recovery community develops, which acts as mutual relapse prevention support. (White & Kurtz, 2006).

New recovery community support organisations are helping anchor recovery within these natural environments. The recent growth in these peer-based recovery support services as an adjunct or alternative to historical addiction treatment is based on the belief that exposure to the personal stories and lives of people in recovery can serve as a powerful catalyst of personal transformation for people suffering from severe AOD problems, and can form the basis of important social learning and reinforcement of recovery messages and values. One of the strongest UK examples is provided by the Lothians and Edinburgh Abstinence Project (LEAP) in Edinburgh, based on a quasi-residential rehabilitation with an intensive community aftercare and recovery programme. Van Melick and colleagues (2013) have shown that merging a commitment to ongoing 12-step group participation with sporting and recreational activities (guitar club, walking club, football teams) has generated a set of recovery champions and activities that have significantly boosted the visibility and accessibility of recovery communities in Edinburgh. This built on existing innovation in Edinburgh characterized by the emergence of the Serenity Café (Campbell et al, 2011) as a visible activity and rallying point for recovery activity in the city.

One of the challenges for developing recovery communities in the UK is around recovery visibility – with the reliance on 12-step groups, although highly effective for those engaged, creates challenges for those not aware of or willing to engage with these groups. This is where both effective linkage processes are essential (eg Manning et al, 2012) but also where a visible recovery model can effectively engage both professionals and peers not currently engaged with 12-steps.

2b. Are there communities that promote abstinence and those which adopt a harm minimisation approach? How are they defined and how do they differ?

It is important to point out that harm minimisation approaches and abstinent based approaches are not mutually exclusive, and both constitute key resources for people at different stages of their recovery journeys. In principle the harm minimisation model should offer a wide range of options including abstinence but areas vary significantly in the extent to which there are clear pathways out of treatment and into recovery. This will in part be reflected in the spending profiles and the extent to which continued commitment to substitute prescribing, acute detoxification and medical treatment are the dominant forms of treatment.

Internationally, there is little evidence that harm reduction or treatment activities create communities outside of those developed through the Therapeutic Community world. In the special issue of the Journal of Groups in Addiction and Recovery (eds Roth and Best, 2012), now published in a book form, all of the examples of recovery communities are primarily focused on abstinence cultures. There is not a single story of needle exchange or methadone maintenance clients generating active communities of recovery. In his website (WIlliamwhitepapers), White interviews Walter Ginter, the manager of a recovery-oriented methadone clinic in New York. However, no data or evidence are presented on the extent to which this has created a community of recovery outside of the clinic or whether there is now evaluation evidence on its community impact within the clinic. So while there is nothing in principle inconsistent about harm reduction approaches and recovery communities, this has not been widely promulgated. One interesting development that White and Torres (2011) explore is the idea that methadone-maintained clients attend residential rehabilitation while maintained on prescriptions – but there is not yet sufficient evidence to suggest that this generates a community of recovery.

2c. Does the delivery of a recovery community have to be driven by a treatment centre and if not what other organisations could be the catalyst?

Studies both authors have been involved in across the UK have provided very strong evidence that recovery communities can emerge and even flourish in the absence of commitment to the process from the mainstream treatment services. This is consistent with the US evidence on recovery-oriented systems of care summarised in “Addiction Recovery Management” (edited by Kelly and White, 2011) in which the emergence of recovery communities in Philadelphia, Connecticut and Chicago is discussed at length.

Indeed, in places such as Liverpool and Calderdale, there is evidence that a recovery community can emerge and flourish without being focused around, or even having the active involvement of, the primary treatment provider (Best et al, 2012). In the UK cases, and in the US, developing a core Recovery Coalition that has both strategic leaders and grass-roots participation from people in recovery (and ideally other key community groups, including family members and a diverse range of community support organisations) can create the critical mass required to develop a recovery community, and is essential in generating what is called the ‘co-production’ of community resources involving professionals and the community.

The creation of a local recovery hub in the community helps to build personal and social capital may help support the development of the recovery community. Recovery community buildings encompasses activities that nurture the development of cultural institutions in which persons recovering from severe AOD problems can find relationships that are recovery-supportive, natural (reciprocal), accessible at times of greatest need (e.g. nights and weekends) and potentially enduring. Recovery community building activities include cultivating local (advocacy) organisations and peer-based recovery support groups, promoting the development of local peer-based recovery support services/institutions focusing on such areas as recovery-focused housing, education, employment and leisure (White, 2009b).

Development of the positive profile of communities and visible promotion of recovery hubs in communities can help to inform targeted community development. This in turn helps to build the necessary assets and empower locally driven community solutions, thus building solutions that are co- produced and thereby more sustainable.

There is significant work – including UK work by the Young Foundation that describes the process of ‘co- production’ where specialist professionals have an early role in community development, support and training but ultimately the goal is that the skills and resources reside in the community and the process
is community-owned and directed (Kretzmann and McKnight, 1999). In the AOD field what this means is that there need to be bridges built to indigenous community resources that will include the mutual aid groups (AA, NA, SMART) as well as graduates and champions of treatment services – the role of professionals should always be peripheral and should be increasingly so over time.

2d. What needs to be in place for a recovery community to develop successfully?

There is a balance to be struck between providing a supportive and creative environment in which people can build their own recovery assets and opening out recovery support as a community wide activity. As outlined above, the key requirements are strong leadership and a clearly defined recovery vision and mission – with access to strategic decision-making (this will typically be the commissioner of specialist services but may be figures in public health, the local authority, etc) linked to a strong coalition of community recovery resources and champions. This fits with the UK Government Drug Strategy (2010) requirement for ‘strategic recovery champions’.

In the work on recovery capital done for the RSA by Best and Laudet (2010) we identified three types of recovery capital – personal and social capital but also community recovery capital. In this model, the requirements from the local environment to support recovery include good acute treatment services, effective links to aftercare and recovery groups, visible recovery champions and recovery groups and adequate availability of housing and jobs. It is assumed that the recovery community can play a dynamic role in engaging and supporting this community. Our model must grow to recognise that our successes are the key to transforming problem areas into viable recovery communities – in other words, a viable recovery community can have an impact on the wider community through a ripple effect involving families, peer groups and neighbourhoods.

The key factor in sustained recovery is often people’s social supports. These supports come from their social networks and community, in other words the assets around them. However, for people to draw on these supports, they need to be visible and accessible, as recovery icons/champions and there is a need for these to function as effective bridges from treatment to sustained recovery. This capacity building approach is essential for communities to be more than recipients of services and to feel empowered and enabled to create change and improved health and life outcomes. There is also a need for recovery sustainability – in our report for the NTA in 2011, Best et al (2011) identified the need for a cohort of established and linked recovery champions (ie not all people in the first few years of their recovery journeys; and for strong bonds among the ‘recovery elders’ to make the community stable and viable).

Social learning of recovery is vital to the process of enabling the growth of recovery capital. Moos (2007) identified social learning and social control as two of the key mechanisms underpinning recovery from addiction. This means embedding yourself in a community of recovery and both taking on board the norms and values of the group and also learning and imitating the recovery techniques and methods of the group. By increasing the availability of positive recovery icons across a system evidence shows that where investment, support and training are provided, individuals in communities are able to transform their own health and create sustained activity to positively influence others. Therefore, primarily it is important to generate a pool of individuals who are recovered or in recovery who will sustain their own journeys by working to help others (recovery champions/ icons). Though this is seen as a major tenet within the ‘service’ part of 12 step, it is a consistent feature of all mutual aid groups – helping others is a part of the recovery journey and is important in maintaining sobriety or abstinence from AOD. In the language of John McKnight, these champions also act as community connectors, who provide links not only to mutual aid support groups, but to a range of community assets and opportunities including courses and jobs. This assertive linkage model respects the individuality of personal recovery by acting as a link to the needs of the individual and not assuming that one model (AA, SMART or whatever else) is either necessary or sufficient. However, as Humphreys and Lembke (2013) point out, the evidence base would suggest that an effective recovery community requires:

  1. access to mutual aid groups
  2. peer involvement in delivering or supporting professional interventions
  3. recovery housing

The 2010 strategy discusses the notion of champions in some depth but relatively little research work has been done in this area, with most of the supportive evidence coming from research on social network effects (eg Best et al, 2012; Longabaugh et al, 2010) or social contagion research (eg Christakis and Fowler, 2010). In the US (see Kelly and White, 2011) the language is more typically of recovery leadership but the meaning is essentially the same. Effective recovery coalitions require powerful and charismatic individuals who can both champion and role model recovery behaviours and act as ‘community connectors’ (McKnight, 2010). They undertake assertive linkage processes, not only to engage people early in their recovery journeys in mutual aid groups, but also in education and training, employment, recreational activities and other forms of community engagement.

The development of recovery communities aims not to promote one treatment option at the expense of another, nor is it the intention for a service to take primacy within a recovery community. Rather, it is to give equal prominence to abstinence and recovery within a wider community system. It will also positively encourage engagement with mutual aid and fellowship available from Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA) and SMART recovery. By developing a therapeutic space that allows cohorts of individuals in recovery to support each other on a recovery process that is much too long and intensive to be restricted to what is available through acute treatment services recovery hubs.

Recovery hubs:

  • are recovery oriented sanctuaries anchored in the hearts of communities
  • are based around physical locations where local communities of recovery can be organised
  • have a commitment to being an umbrella organisation where different pathways and philosophies of recovery can flourish
  • places where Recovery Support Services are designed, tailored and delivered by local Recovery communities
  • are fuelled by a comprehensive Volunteer System – including people in long-term, sustained recovery
  • extend into the fabric of our communities and make a valuable contribution to that community
  • provide safe housing for those most vulnerable
  • provide a space for people in recovery to learn skills and to be educated to support them back into work when suitable
  • provide a space for relaxation and enjoyment
  • are family inclusive

2e. Are there any obvious geographical areas where a recovery community would be likely to successfully develop?

Though a recovery community can be developed in any place if we look at speed of transition certain areas have pre existing drivers to create movement. As stated above experience shows us where access to a therapeutic programme of recovery doesn’t exist alongside a lack of mutual aid in a locality, capacity building in the local community appears limited. It is perhaps no coincidence that recovery communities have predominantly developed in areas where residential rehabilitation/recovery community organisations are evident. Certainly a potential criteria for where a recovery community may flourish could include:

  • Strong treatment services that have high substance free completions
  • The availability of an abstinent therapeutic programme
  • Supportive community services
  • Effective links to housing and community groups
  • Established mutual aid or other peer communities

3. Evidence of Effectiveness

3a. What is the evidence for the effectiveness of Recovery Communities?

There have been relatively few research studies conducted on recovery communities in the UK. The international evidence base on recovery is limited by three factors:

  1. Much of the evidence is dated;
  2. Much of it is based on alcohol rather than illicit drugs; and
  3. Almost all the evidence originates from the United States.

There has been very little commitment to recovery research in the UK and much of what has been conducted has been based on the work of the current authors. Where there has been more work has been around the Therapeutic Communities, with Kaplan and Broekaert (2003) arguing that at the point of departure and through aftercare is the key point for the emergence of a recovery community. However, there is no published literature on this in the UK. Van Melick et al (2013) have assessed the impact of a quasi-residential rehabilitation on the emergence of a recovery community in Edinburgh and have concluded that the emergence of a network of peers and mentors in the community is essential, with the treatment service (LEAP) acting as the hub for this program.

One of the authors (SH) has recently been involved in studies measuring the recovery resources available across England in six localities, encompassing a number of developed recovery models. By examining the inherent assets and supports that exist amongst individuals, within organisations and the wider communities, the work attempts to give an insight into what is already working in a locality and accentuate positive ability and capacity to activate solutions. By comparing the social networks and meaningful activity levels between individuals using treatment services and those currently abstinent clear themes emerge. One critical aspect appears to be the amount of positive recovery capital a person can draw on – capital consisting not only of personal resources, but also resources and support drawn from the community, such as peer support. Most importantly the number of people a person had in recovery in their own network correlates with the level of personal recovery capital and meaningful activity.

This is reflected in the work that Best et al (2012) completed with three English DAAT areas where recovery social networks were predictive of wellbeing reflecting this need to have access to community recovery resources. A vibrant recovery community rests on multiple access points and support systems and a visible and attractive community of activities and groups.

The resolution of severe alcohol and other drug problems is mediated by the processes of social and cultural support (Brady, 1995; Laudet et al, 2006; Longabaugh et al, 1993; Spicer, 2001). Both general and abstinence-specific social support influences recovery outcomes, but abstinence-specific support is most critical to long-term recovery (Beattie & Longabaugh, 1999; Groh et al, 2007). The risk of relapse following recovery initiation rises in relation to the density of heavy drug users in one’s post-treatment social network and declines in tandem with social network support for abstinence (Bond et al, 2003; Dennis et al, 2007; Mohr et al, 2001; Weisner, Matzger, & Kaskutas, 2003; Best et al, 2008). The evidence base generally for recovery communities rests on two primary groups – the 12-step fellowships (particularly AA) and Therapeutic Communities.

Role of Recovery Mutual Aid

Participation in MA groups such as Alcoholics Anonymous (AA), in conjunction with specialist treatment, has been found to enhance long-term recovery rates and improve overall functioning, as well as reduce drug-related costs to society (Kelly & Yeterian, 2008; White, 2009). Studies regarding the effects of participation in recovery mutual-aid societies on long-term recovery outcomes are limited in scope and methodological rigour, although the span and scientific credibility have increased significantly in the past decade (Humphreys, 2006). Most of what is known about mutual-aid and recovery outcomes is based on studies of the effects of involvement in Alcoholics Anonymous of individuals following addiction treatment. Seen as a whole, these studies conclude that participation in recovery mutual-aid societies typically enhances long-term recovery rates, elevates global functioning, and reduces post-recovery costs to society (White, 2009a).

Not only do MA groups provide support for the maintenance of abstinence, but also provide a safe forum in which recovering individuals can share coping strategies and life skills, as well as greater social support (Laudet, Magura, Vogel, & Knight, 2000). As Kaskutas (2009) has shown, there is a strong and consistent evidence base that attendance at 12-step meetings in particular is associated with improved alcohol outcomes, with greater attendance associated with greater gains. Kelly et al (2012) have gone further to show that AA helping – ie doing active service at meetings – is a particularly strong predictor of positive outcomes. The period immediately after leaving AOD treatment is a particularly high-risk time for relapse, and there are substantial benefits from strong linkages between treatment facilities and peer-supported recovery groups (Best et al., 2010). Further, Best et al.(2011) has shown that, for drug users and drinkers in recovery, greater community engagement is associated with significantly better quality of life.

Therapeutic Communities

Therapeutic communities have proved to be effective in reducing substance use and criminality. Research has shown that where therapeutic communities are bolstered by an aftercare programme, criminal justice outcomes are improved. In a study by Wexler et al (1999), only 27% of therapeutic community and aftercare programme completers returned to custody (Sacks et al, 2004), compared with around 75% of control group members.

Research undertaken on TCs in the USA (Hiller, Knight, Saub and Simpson, 2006) has shown that, during treatment, risk taking reduces somewhat and social conformity increases modestly. In terms of treatment outcomes and effectiveness, TCs have been shown to produce good outcomes when combined with appropriate aftercare.

A brief summary of our own contribution to this area is outlined below:

Best et al (2013): The emergence of a recovery coalition and recovery champions in Barnsley demonstrated the positive impact of commissioner commitment to recovery supplemented by a training programme that enabled the recruitment of the Barnsley Recovery Coalition. This group of workers and peers in recovery generated a series of activities and events that established a vibrant recovery model in Barnsley.

Van Melick et al (2013): Based on LEAP (the Lothians and Edinburgh Abstinence Project), the authors assessed the impact of peer support and engagement on wellbeing and showed a strong association between the wellbeing of clients and their peer ‘buddies’ in the community.

Best et al (2012) assessed the emergence of social networks supportive of recovery in three English DAAT areas – Calderdale, Liverpool and the Wirral. There were issues around the sustainability of the recovery communities in some areas, but a very strong and committed vision to generating visible recovery partnerships based on a range of professional and community services.

Best et al (in press): Examined the emergence of a recovery community in York based on relatively small mutual aid group participation but centred on a small group of visible and well networked champions.

Similarly, in a study funded by the Home Office, Landale and Best (2012) showed the importance of active engagement in meaningful activities. In this study, a small cohort of drug using offenders were assertively linked to sporting activities resulting not only in reductions in offending and substance use but in active improvements in personal and social wellbeing and in community connections.

In summary, the US evidence would conclude that the key components of an effective recovery-oriented system are:

  • strong links to mutual aid groups (in particular AA)
  • recovery oriented housing
  • peer involvement in professional treatment delivery
  • system management focusing on the community and continuity of care models

In the UK, our much smaller evidence base would suggest:

  • the benefits of recovery hubs
  • visible recovery communities and coalitions of peers and professionals
  • clear pathways to a range of post-treatment recovery supports
  • the critical importance of peer-recovery social networks

3b. What are the key factors that determine likely long-term success? What would success look like in the development of a Recovery Community?

There is clear evidence that ‘recovery works’ but it takes time (between 5-10 years according to the US models, Kelly and White, 2011) and dedication from a coalition of policy makers, professionals and communities. The pockets of recovery demonstrated in the areas we have worked in have shown what can be done to develop a recovery community and raise visibility locally. This offers ideas for how such a community can be grown, through strong community connections, the growth of mutual aid, voluntary opportunities, family support, sober living housing, a ‘safe’ hub, social enterprise and peer outreach. The challenge is how to ensure that opportunities are available whatever pathway a person chooses to take and that the lines between specialist services and groups are aligned, so that support is locally based, draws on the assets of individuals and those beyond statutory agencies and appears seamless to the community it purports to support. It is also important to avoid a ‘two worlds’ model where clients in specialist treatment have no opportunities for access to wider recovery supports.

Key learning points from the community work we have undertaken are:

  1. Communities are where recovery takes place in the long term and communities themselves will have a recovery journey and will benefit from the activities of the recovery community.
  2. The focus should be on strengths in the community based on an inventory of assets categorised (individual skills and resources, associations and institutions in that locality). The assumption is that indigenous resources will vary area to area and so a standard formula is not possible, and models developed to tap into the existing resources in each area.
  3. There is empirical support for the capability of peers and volunteers in delivering community-based programmes effectively.
  4. Communities have a key role to play in sustaining and enhancing treatment gains. While specialist treatment services can initiate treatment processes (RETHINK, 2008), it is the community resources that will sustain those initial recovery gains.
  5. There are a wide range of functions that community groups can play in the recovery journey, that are both dedicated to overcoming addictions and to broader social growth.

From a US perspective, the evidence of transition to a recovery-oriented system and model is characterised by gradual transitions to a balanced system of recovery-oriented professional interventions and peer-delivered communities. There are three essential methods that potentially enhance the power of the community in the long-term recovery process: recovery community building, in reach and outreach:

Recovery community building encompasses activities that nurture the development of cultural institutions in which persons recovering from severe AOD problems can find relationships that are recovery-supportive, natural (reciprocal), accessible at times of greatest need (e.g. nights and weekends) and potentially enduring. Recovery community building activities include cultivating local recovery community organisations (RCO’s) and peer-based recovery support groups, promoting the development of local peer-based recovery support services/institutions focusing on such areas as recovery-focused housing, education, employment and leisure (White, 2009b). The current work of one of the authors (DB) suggests that there is a key component of this that is about shifting the social identity of addicts to a recovering identity through engagement and participation in social groups (such as AA or recovery communities) that bind and engage the person in recovery activities (Best et al, in press).

In-reach is the inclusion of indigenous community resources within professionally directed addiction treatment. There are indications that a visible local recovery community can ‘expose’ recovery to those who are not part of that community. For clients in addiction treatment, affiliation. In-reach strategies include engaging each person’s family and social network in the treatment process, establishing strong linkages between indigenous recovery support groups and addiction treatment institutions; alumni associations and volunteer programmes to saturate the treatment milieu with people representing diverse styles of long term recovery. This involves both embedding community recovery links in treatment services and actively encouraging specialist treatment staff to engage in the recovery communities.

This might involve joint training between formal treatment providers and community and mutual aid groups; information sharing; joint assessments and case reviews and regular visits and exchanges. This is one mechanism for overcoming a ‘silo’ model where professional treatments exist in a separate and unconnected realm to the recovery activities in communities and involuntary organisations. Benefits from mutual-aid is often influenced by worker attitudes toward mutual aid, the style of linkage (assertive versus passive, degree of choice, and personal matching), and the timing of linkage (during treatment versus following treatment). The potential positive effects of recovery mutual-aid participation are often not achieved due to weak linkage procedures and high early dropout rates Thus, services that have introductory sessions from mutual aid groups and who include people in recovery in the brief and full assessment processes are examples of integration of community and treatment models, based on an in-reach approach.

Early engagement with community supports and mutual aid is not straightforward and individuals will frequently need support and encouragement. Timko and colleagues (2006) assessed the effects of an intensive referral approach to 12-step facilitation programmes in a USA treatment setting, self-help groups arranged the recruitment of a volunteer to meet the patient and take them to a meeting. This was associated with significantly greater attendance than standard referral by advice or leaflet and resulted in greater engagement with 12-step at six month outcome point as well as better drug and alcohol use outcomes at the follow up. More recently, Timko and colleagues (2007) developed the MAAEZ model (‘making alcoholics anonymous easier’) and have evidenced its impact in initiating engagement with 12-step. In a London-based study, Manning et al (2012) found that active linkage to AA, NA or CA led to better meeting attendance on the wards, in the three months after treatment completion and lower levels of substance use in this three month period. However, there is almost no research in applying these principles to other forms of recovery groups or meaningful activities, and this would be a key potential area for research.

Outreach is the extension of professional addiction treatment services into the life of the community, including supporting clients within their natural environments following the completion of primary treatment. In other words, it is critical that bridges are built between professional and community groups and that professionals make the time and effort to familiarise themselves with the community support groups available for their clients.

Outreach strategies include community education efforts, early case identification and engagement via formal outreach, screening and brief intervention programmes, linking local harm reduction and recovery support resources, delivering services in nontraditional service sites, and enhancing the visibility of people in long term recovery in a range of community settings. In addition to this, treatment services need to introduce strength based assessment procedures, offer service delivery sites that are community integrated with built in post treatment check ups and supports. This links to an established model in the US – Recovery Management Check-ups (Dennis et al, 2007) who have shown that assertive (and peer-delivered) telephone support to people in early recovery has two benefits – both by increasing the time to relapse and by improving the speed of treatment re-engagement in those who do experience lapses.

Social learning of recovery is vital to the process of enabling the growth of recovery capital. By increasing the availability of positive recovery icons across a system evidence shows that where investment, support and training are provided, individuals in communities are able to transform their own health and create sustained activity to positively influence others. The US evidence outlined by Kelly and White would suggest that integration is central – integration into the community but also integration among the recovery champions and integration with professionals where possible. In our UK work in Barnsley and York, one of the key challenges was to create a supportive and linked cohort of recovery leaders and champions united under a single vision or mission for recovery, and who support each other. It is critical in developing a recovery leadership model that there is a supportive model for peers who are able to support and help each other.

In building a successful recovery community, there are a number of key developments:

  1. A successful coalition of the key community recovery groups and individuals including user and carer groups, mutual aid groups and local community groups. Emerging technologies may well be utilised to support such partnerships. This should also involve active engagement in community resources including housing, community development, public health and so on.
  2. They should be linked under strategic guidance to key local decision makers including but not restricted to local service commissioners and public health.
  3. There should be multiple, clear and visible paths to recovery including paths from professional services to the recovery community.
  4. Professional alcohol and drug treatment staff and managers should have had recovery training, mutual aid specific training and demonstrated commitment to recovery approaches. This can be tested by recovery quality assurance and audit to prevent ‘spray on’ recovery – where the word is used liberally but has no impact or depth. One of the key advances in this area would be the development of quality standards around recovery-oriented clinical practice for services in the UK.
  5. There needs to be evidence of an emerging recovery-oriented system adhering to the evidence base laid out for the Centre for Substance Abuse Treatment by Sheedy and Whitter (2009), and effective linkages and pathways to housing, employment and education, community activities and recovery support groups.
  6. There needs to be a training and development package for recovery champions consisting of both personalised training plans and group supervision and support activities.
    There needs to be key strategic commitment to a recovery model that includes adequate financing and a performance management process involving both recovery process and outcome markers for which both professionals and the recovery community are held accountable. By promoting the continual evaluation of the model it is hoped evidence based practice can develop.

Thank you to Stuart for allowing us to share his work.

If you would like to contribute to the RecoveryPlaces blog, please get in touch.

 

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