Extending the Professional Recovery Model

Strict adherence to continuing-care plans is crucial if the addiction field intends to improve recovery outcomes for those treated for chemical dependency. The responsibility for ensuring this adherence, and for the lack of adherence to date, rests squarely upon those of us in the addiction profession. For too long we have done what we have perceived as “our job” while clients were within our care, and then hoped for the best as they made the very difficult transition to early recovery—often with predictably disappointing results. If we are to continue to evolve as a profession and improve our efforts' results, we have a responsibility to create new paradigms for continuing-care plan implementation and accountability.

Addiction professionals know that treatment for chemical dependency works. Yet 40 to 50% of clients experience a relapse during their first year out of residential treatment.1 For many years, solutions have been in place to ensure long-term, sustained recovery from chemical dependency. Those solutions are found in the form of “assistance programs” that are generally accessible only to licensed professionals in regulated industries such as the medical profession and the airline industry.

Last year, when our addiction consulting firm Addiction Intervention Resources (A.I.R.) began to research ways to improve our clients' posttreatment outcomes, we were amazed by the rates of success for professionals participating in these assistance programs. The question we continued to raise was: If this type of program is so successful, why isn't it available to the general public? After a year of research and trials, we are convinced that structured monitoring programs that focus on adherence to the continuing-care plan hold the key to improving recovery rates for all who suffer from chemical dependency.

Chemical dependency is a chronic illness. Other chronic illnesses, such as asthma and diabetes, see relapse rates similar to those for chemical dependency.2 But there is a difference between treatment and recovery for chronic illness in general and for chemical dependency. This lies in addiction professionals placing the responsibility for following the prescribed continuing-care plan solely in the client's hands.

For most chronic illnesses, regular follow-up visits to a physician are a standard, accepted practice. During a follow-up visit a physician can monitor a diabetic patient's health and determine if the continuing-care plan (involving medication, diet, and exercise) is being followed. With chemical dependency, follow-up is generally not part of the continuing-care plan. Why? A mother and father certainly would ensure that their diabetic child followed through with the recommended continuing-care plan from their physician. However, loved ones too often do not understand the significance of continuing care for someone with chemical dependence.

Inventory of existing programs

In an effort to identify what was available and what was working in continuing-care efforts for chemical dependency, our organization looked at some of the more commonly used modalities. One of the assistance programs that we looked at closely, designed specifically for airline pilots struggling with alcohol and drug problems, is based on the Human Intervention and Motivation System (HIMS). The purpose of HIMS is to identify the pilot's problem, intervene, refer the pilot to the appropriate treatment facility, and then ensure that the pilot maintains sobriety. The overriding goal is to allow the Federal Aviation Administration to allow the pilot to resume flying.3 The data show that airline pilots have recovery rates as high as 92 to 95%.1 This represents a 32 to 45% improvement over the recovery rate found in the general population.

HIMS has been used as the model for the majority of assistance programs that deal with licensed professionals such as doctors, nurses, and attorneys. The end result has been increased rates of recovery.

We examined two other more common and accessible forms of assistance programs that are available to the general public. “Monitoring” programs typically involve toxicology screens combined with self-reporting on posttreatment activities. After reviewing several of these programs, we concluded that they were too narrowly focused on the toxicology screening component. Also, dependent as they were on self-reporting, they failed to provide an accurate assessment of an individual's recovery. And with little to go on other than toxicology screen results, they lacked any allowance for relapse in the treatment of a chronic condition and were ultimately purely punitive. While monitoring may work for some individuals, it focuses too heavily on producing a clean urine sample and misses the big picture—a successful life in sobriety.

The other type of assistance program we looked at is referred to as “sober coaching.” A sober coach is typically an individual who works one-on-one with a client over an extended period of time in an effort to keep the client sober. Sober coaching comes in many forms; these services can range from structured, short-term programs of two to five days to long-term coaching where the sober coach actually moves into the client's home. Sober coaching can be useful for some individuals in the process of recovery, but we see it as only one element of a more comprehensive solution.

A.I.R.'s approach

Based on our research and a belief that a new paradigm was necessary, we began to develop a new set of recovery management services and tools. We integrated proven methodologies, including HIMS, to design a comprehensive relapse prevention program that would improve recovery outcomes for our clients (we consider our “client” under this effort to be the recovering person's family or workplace). The objective was to develop a replicable tool designed to predict and prevent relapse, providing clients with access to resources and ongoing support and ensuring accountability for the recovering individual.

The “Recovery Assurance Plan” model as developed is built on a one-year timetable and divided into three distinct phases. Treatment Liaison begins while the patient is in treatment. Through contact with a counselor or other contact person at a treatment facility, a plan is formulated based upon the work accomplished and knowledge gained during treatment to prepare for the transition back to day-to-day life. Concurrently, time is spent educating the family and/or workplace on how to support the patient's recovery. In order to do this successfully, professionals would:

• work closely with treatment center staff to gain an intimate understanding of treatment outcomes, relapse triggers and, most importantly, elements of the continuing-care plan;

• identify resources in the recovering person's local community that will support and reinforce the prescribed continuing-care plan; and

• identify resources that would be of benefit to the family, such as therapists, family programs, and organizations such as Al-Anon.

The Re-Entry Bridge phase focuses on providing a smooth transition from the treatment center environment back to the home or workplace. This is achieved through a family and/or workplace meeting, mediated by a recovery-management clinician. At this meeting, guidelines, boundaries, and expectations for the recovering person over the next 12 months are discussed and agreed upon. The most critical element of the Re-Entry Bridge involves properly implementing the continuing-care plan prescribed by the treatment center and aligning the identified local support resources.

The Monitoring phase is designed to verify and report on ongoing adherence to the continuing-care plan and sustained sobriety. The core of this phase is regularly scheduled contact between the patient and the recovery-management clinician. At various stages in the contact schedule, the patient will be screened with a relapse predictor, such as the AWARE (Advance Warning of Relapse Questionnaire).4 In addition, all parties who have a vested interest in the recovery process, such as family members, sponsors, therapists, and outpatient group members, are contacted to corroborate achievement of continuing-care milestones. Finally, random toxicology screens are introduced and conducted on an ongoing basis.

Client reports are generated following each contact, and progress reports are issued monthly. If at any time the patient deviates from the program or the continuing-care plan, immediate steps are taken to get the person back on track.

If all addiction professionals embrace this kind of model, where implementation of the continuing-care plan is carefully monitored, professionals and the clients they serve will see a number of benefits. This model will:

• facilitate the transition from treatment to recovery;

• complement and reinforce prescribed continuing-care plans;

• create personal accountability and responsibility, increasing the potential for long-term sobriety;

• generate better outcomes and improved rates of recovery;

• expedite the return to work, home, or school;

• provide third-party validation and compliance documentation;

• educate and support the family or workplace on their role in the recovery process;

• remove family members and workplace supervisors from the role of monitor; and

• be time- and cost-effective.

Based on the success that professional assistance programs have shown over a number of years and the positive short-term outcomes achieved during our trials, we insist that it is time to make applicable continuing-care models available to the general public. Our jobs require us to be responsible for providing the very best tools for recovery to any and all who seek them. Models such as the Recovery Assurance Plan outlined here offer the next step for the field.

References

1. Kizilos P. Airline pilots soar to success in recovery. Hazelden Voice 1998; 3 (1): 1-2.
2. McLellan AT, Lewis DC, O'Brien CP, et al. Drug dependence, a chronic medical illness. JAMA 2000; 284:1689-95.
3. Martinez E. Addressing alcohol abuse. Air Line Pilot 2004 ;(Apr.): 17.
4. Miller WR, Harris RJ. A simple scale of Gorski's warning signs for relapse. J Stud Alcohol 2000; 61:759-65.