Centers embrace recovery planning

“What should I say to my co-workers and friends who don’t know I went to treatment?”

“How can I fit my new meditation practice into my schedule when I’m back home?”

“What if I don’t like 12-Step meetings?”

“How do I rebuild my relationship with my spouse?”

“How can I make my work schedule more manageable?”

“How do I find a sponsor?”

“I’ve never had a hobby; how can I find one now?”

“Now that I’m clean and sober, what’s next?”

In 2007, when I started the alumni program at CeDAR, the Center for Dependency, Addiction and Rehabilitation, these are the kinds of questions patients were asking when they left our treatment program. I was fairly new in recovery and eager to learn how I might support our alumni. I knew all too well how tricky early recovery could be.

As the staff person who kept in touch with patients after they left treatment, I quickly discovered that whether patients returned home after their primary care experience or participated in a continuing care program, most described early recovery as a demanding and baffling time. Dealing with the choices and challenges of “real life” was daunting.

As I continued to connect with alumni, I noticed some common denominators among those who were experiencing the most success and satisfaction with their lives in recovery:

• They were committed to a vision of recovery that included a better life than the one they had been living.

• They identified and used assets (people, places and things) that supported their recovery efforts.

• They used strategies for self-management and self-care that they had learned in treatment, and were open to learning more.

If these behaviors constituted markers of success, I began to wonder how they might be intentionally taught to patients to enhance their early recovery efforts.

Coinciding with these informal observations, several other developments in the addiction field were influencing my thinking:

• William White’s book, Pathways from the Culture of Addiction to the Culture of Recovery, introduced me to the idea that recovery is indeed a journey—a trip from the culture of addiction where unhealthy rituals, activities and values support dysfunctional behavior to a culture of recovery where healthy rituals, activities and values support wellness and a positive way of engaging with others and in life. In his book, White suggests that treatment professionals can be the “welcome wagon to the culture of recovery” by teaching patients its rules, etiquette, language and values during their treatment episodes.1

• At the 2005 National Summit on Recovery, professionals from all walks of the addiction field came together with policy-makers, people in recovery and other stakeholders to reach consensus about guiding principles of recovery and elements of recovery-oriented systems of care (ROSC). Based upon the discussions at this summit, recommendations were posed for the treatment and recovery field. Suggestions to treatment providers included a call to “offer a full range of recovery options that begin in treatment and continue beyond the treatment episode,” states the Substance Abuse and Mental Health Services Administration's (SAMHSA's) summit report.

• The organizing principle for providing care to persons with addiction started to shift from a pathology-based acute care model to a long-term recovery paradigm. Treatment providers were considering recovery management models of care that enhance individuals' and families' quality of life by providing services that sustain long-term recovery.

• The notion of “recovery capital” started to appear in the addiction literature. Cloud and Granfield defined recovery capital as the “breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from alcohol and other drug problems.”2 They added that “both the quality and quantity of recovery capital play a major role in predicting recovery success” and that individuals could in fact actively work on increasing their recovery capital.

• Research in the area of peer support services indicated that this type of support can be valuable to those overcoming substance abuse challenges.3 It is a flexible approach in which people with common experiences learn and grow. SAMHSA has supported this type of programming by funding more than 30 peer recovery support centers across the United States.

Taken together, I believed that a blend of these ideas offered an opportunity for the Alumni Services department at CeDAR to create an innovative program that could empower our patients in their long-term recovery efforts. This type of program could be implemented in concert with the clinical, medical and educational components already in place.

As I was considering all of these events and trends, Steve Millette was hired as CeDAR's new executive director in 2010. Millette is a strong proponent of ROSC, and his strategic plans for CeDAR included integration of a recovery management model of care. As he and I began to formulate how we could operationalize ROSC principles, recovery management and peer coaching at CeDAR, we decided that the Alumni Services department would be a logical place from which to spearhead the project.

At many treatment centers, alumni activities kick into gear after patients leave treatment. Our intention was that patients would get connected to CeDAR’s alumni program by starting the recovery planning and coaching program as soon as they entered treatment.

Because we were envisioning a new role for our Alumni Services staff, we changed their title to “recovery support services specialists” (RSSS). Three full-time RSSS currently serve CeDAR patients and alumni.

Each RSSS is assigned a caseload of patients and meets individually with those patients three times over the course of treatment. Each RSSS also is responsible for teaching two recovery classes every week; patients in these classes learn what they need to know to participate in the recovery planning process. Once patients leave CeDAR, the RSSS follows up with recovery coaching phone calls.

The CeDAR RSSS are all in recovery and are alumni of the CeDAR program. Although they are paid staff members, they work in a peer support capacity with patients from the context of their own recovery experience. They act as mentors, cheerleaders, motivators, allies and problem solvers. A training program was put into place so that they could learn how to be effective in these new recovery planning and coaching roles.

Recovery planning

As opposed to treatment planning where staff generally direct and control the planning process, recovery planning makes patients responsible for developing their own plan, with help from the RSSS.4 The recovery plan outlines the activities patients have chosen to pursue that will support their transition back home or to another level of care.

This plan complements the continuing care plan that is developed by staff. The RSSS works with each patient to outline the practical steps necessary to follow through on continuing care recommendations and to accomplish personal and professional goals. Patients' questions about how to carry out realistically the important tasks that will support their sobriety are addressed through recovery planning.

Here is an outline of the information and skills that support patients through the recovery planning process. For most of these classes, CeDAR alumni are invited to participate and share their perspectives, experiences and resources.

Intentional living practices. Every journey begins with a purpose and an intention: hopes for what we want to accomplish and how we want to experience the adventure. People in early recovery often are not clear about those possibilities.

The purpose of intentional living activities is to provide patients with a framework for clarifying their vision for their life in recovery, to assess where they are now in relation to that vision, and to become aware of the gap between “here and there.”

Goal setting and action planning. How do we actually get where we want to go? As people in early recovery navigate the demands and stresses of their lives, one of the pitfalls they often face is lack of clarity. They make statements such as, “I want to have a better relationship with my wife,” “I want to get in shape,” and “I want to go back to school.” All of these are great ideas, but require careful planning. Without thinking out the steps, one can become discouraged and give up.

An important piece of recovery planning involves helping patients learn a process for problem solving that they can use again and again. Teaching a strategy for defining goals, identifying small steps to reach those goals, determining how to be accountable, and knowing when the goal is reached helps clients devise realistic recovery goals and set up the conditions or baby steps needed to achieve those goals.

Recovery capital. Cloud and Granfield defined four components of recovery capital: social, physical, human and cultural.2 They went further to suggest that recovery capital plays a major role in predicting recovery success and that people can intentionally and positively grow their recovery capital.

Teaching about recovery capital helps patients discover where they have strengths and where they need to build the relationships and resources that will support their recovery. In recovery classes and meetings, the RSSS guides patients through an assessment of personal capital. With this information, patients identify what they can do to make use of the capital they already have and to increase their recovery capital where needed.

Recovery-related resources. A wide array of recovery-related resources become available to patients when they leave treatment. Hundreds of mutual-aid support groups provide the fellowship and community that is so important in recovery. Web-based recovery resources offer social communities, education and entertainment. There are recovery schools, recovery community organizations, recovery homes and recovery advocacy groups. Patients must learn about these recovery resources and how to access them.

Integration with the culture of recovery. Developing a relevant program requires determining the specific needs of individuals. This requires that we understand the “culture of recovery” to which clients are returning and the skills needed to succeed in that culture. For example, clients who are heading back to work may need assistance to improve their communication skills. Recovery planning classes for college-age patients may include activities on résumé writing and interviewing skills. Other patients may need to learn parenting skills or how to manage finances. If providing this type of information in recovery planning classes falls outside the scope of a treatment program, RSSS can suggest to patients resources that may be pursued after treatment.

Recovery coaching

As an adjunct to the recovery planning process that occurs while in treatment, patients receive continued support from RSSS once they leave treatment. The recovery planning document that is created during treatment is used as the basis for this ongoing coaching relationship.

At CeDAR, recovery coaching is provided through follow-up calls. RSSS call former patients (now alumni) one week after they leave treatment, then continue calls at these intervals: one month, three months, six months, nine months and one year. RSSS staff received training in Motivational Interviewing and other communication processes to help them conduct these phone conversations.

The goals for these calls are to empower clients to use the information and skills they learned while at CeDAR and to reinforce their engagement in positive activities that will support their recovery. In cases where former patients are struggling, these follow-up calls can assist them in getting the help they might need.

The goal setting and action planning strategies learned in recovery classes are used during these calls. Clients are encouraged to reflect on their recovery capital and to continue to build their assets where needed. As alumni proceed on their recovery journey, the focus for these calls changes to reflect clients' ongoing needs, and the clients' recovery plans continue to evolve.

Does it work?

I continue to work in a consulting capacity with the recovery support services specialists at CeDAR as they implement their recovery planning and coaching program. I also am working with the leadership and alumni staff at Lakeview Health Center in Jacksonville, Fla., where a similar program is being developed and implemented.

Although the Lakeview program is very new, staff already are reporting record attendance at their alumni meetings. Leadership and staff credit this increase to the classes and coaching services they have started to provide.

At CeDAR, preliminary data collection indicates that patients are benefiting from the recovery planning and coaching programs. To date, the RSSS continue to engage with nearly 70% of the patients who entered treatment, and among those they reached, 97% reported that they were still clean and sober. If we assume that those who were not reached are not sober, the overall sobriety rate drops to 71%, which is still a very positive outcome.

CeDAR RSSS also report that former patients are active alumni and are engaging in more alumni and recovery activities. These alumni are reaching out for help when needed. They report that they are successfully navigating the challenges of early recovery. They are talking with others about CeDAR, and are acting as champions for CeDAR's program.

The recovery planning and coaching program is one component of a continuum of services offered to patients at CeDAR. These services, provided through the alumni department, complement the full range of treatment resources delivered at the facility. A recovery planning and coaching program can be a relevant service at any treatment center that is interested in supporting its clients’ long-term recovery in an innovative and sustaining manner.

Lorie Obernauer, PhD, founder and president of LO Group, Inc., provides consultation and coaching services to organizations and individuals in the area of addiction recovery management. In her past position at CeDAR (the Center for Dependency, Addiction and Rehabilitation at the University of Colorado Hospital), Obernauer pioneered an innovative recovery support services program. She also is the founder of Treatment Professionals in Alumni Services (TPAS), a national organization that champions professionals providing long-term recovery support programs and initiatives.

References

1. White W. Pathways from the Culture of Addiction to the Culture of Recovery. Center City, Minn.: Hazelden Publishing; 1996.

2. Cloud W, Granfield, R. Conceptualizing recovery capital: expansion of a theoretical construct. Subst Use Misuse 2008;43:1971-86.

3. White W. Peer-Based Addiction Recovery Support. Chicago: Great Lakes Addiction Technology Transfer Center; 2009.

4. Borkman TJ. Is recovery planning any different from treatment planning? J Subst Abuse Treat 1998;15:37-42.

There are many dedicated professionals working in treatment organizations across the country who serve alumni and others in long-term recovery. A national membership organization, Treatment Professionals in Alumni Services (TPAS), provides a forum for these professionals to learn, collaborate and develop best practices in alumni and recovery support services programs. Members believe that by joining forces, they can develop strategies that will benefit their clients and their organizations.

If you are interested in learning more about TPAS and how to get involved with others who are creating alumni and support services programming, visit www.tpasrecovery.org or contact Lorie Obernauer at lorie@lorieobernauer.com. TPAS intends to be a major part of a cutting-edge shift in the addiction treatment and recovery paradigm.