4. Recovery precursors – RETHINK
(2008)
Safe place to live
Basic management of physical and psychiatric
distress
Basic human rights and choices
Recovery time course
Alcohol 4-5 years
Opiates 5-7 years
5. Why do people recover? Moos (2011)
MODEL MEANING
1. Social control Bonding and support; goal direction
(from family, friends, etc); structure
and monitoring
2. Social learning Observation and imitation of family,
peers and mentors; learning
positive and negative consequences
3. Stress and coping Building self-efficacy and self-
confidence; developing effective
coping skills
4. Behavioural economics Involvement in protective activities
– alternative rewarding activities
6. Do people get better?
Calabria et al (2010)
Systematic review of remission papers between
1990 and 2009
“Almost one quarter of persons dependent on
amphetamine, one in five dependent on cocaine,
15% of those dependent on heroin and one in
ten dependent on cannabis may remit from
active drug dependence in a year” (P747-748)
“The estimates suggest that persons who meet
criteria for drug dependence at a given point in
time have a relatively high chance of remitting
within a short time frame” (P747)
7. WHAT IS RECOVERY CAPITAL?
Granfield and Cloud (2008) define recovery capital as
“the breadth and depth of internal and external
resources that can be drawn upon to initiate and
sustain recovery from AOD [alcohol and other drug]
problems”.
White and Cloud (2008): Stable recovery best
predicted on the basis of recovery assets not
pathologies
8. Definitions of social capital
The sum of resources, virtual or actual, that
accrue to a group through possessing a durable
network of relationships (Bourdieu)
Features of social organisation such as networks,
norms and social trust (Putnam)
A culture of trust and tolerance in which
extensive networks of voluntary associations
emerge (Inglehart)
Capacity of individuals to command scarce
resources by virtue of their membership in
networks (Portes)
9. Indicators of social capital
Orford (2008)
General trust in others
Feeling of belonging to the area
Relations with neighbours
Feeling safe / trust in the police / low crime rate
Existence of and participation in social networks
Low migrating out rates
Social pro-activity / helping others
10. Forms of social capital
Szreter and Woolcock (2004)
1. Bonding: trusting and cooperative relationships
between members of a network who share an
aspect of social identity
2. Bridging: relations of respect and mutuality
between people who know they are not alike in
some respect
3. Linking: norms of respect and development of
trusting relationships between people
interacting across explicit formal or
institutionalised power barriers
11. Ziersch‟s (2005) model of social
capital
SOCIAL CAPITAL SOCIAL CAPITAL
INFRASTRUCTURE RESOURCES
Cognitive: Trust, Social support
reciprocity Social cohesion
Civic activities
Structural: Formal
networks, informal
networks
12. Elements and dimensions of
community identity (Orford, 2008)
Residents‟ perceptions of the distinctiveness of their community
Residents‟ perceptions of the special character of the community
Residents‟ perceptions of their own affiliation or belonging
Residents‟ perceptions of others‟ affiliation or belonging
Residents‟ reasons for their identification
Residents‟ orientation to the community (personal investment,
attraction, safety)
Residents‟ evaluation of the quality of community life
Residents‟ perception of others‟ evaluation of the quality of
community life (community spirit, friendliness, cooperation)
Evaluation of community functioning (community services, leisure
services, health services, opportunity, material quality of life,
quality of the environment)
13. Collective efficacy
Sampson (2008)
Defined as: clear norms, a high level of mutual
trust, low level of fear and a willingness to share
Based on data showing the impact of
neighbourhood on criminality and mental health
in adolescents
Directly linked to community resources –
childcare, education, recreation, health,
employment, opportunity and stability of the
resident population
14. Best and Laudet (2010)
Personal Social
Recovery Recovery
Capital Capital
Collective
Recovery
Capital
15. Mapping the recovery journeys of former
drinkers in recovery – Hibbert and Best
(2011, Drug and Alcohol Review)
16. “The Power of Recovery”
(Personal communication with Phillip Valentine, Executive
Director, CCAR, Connecticut Community for Addiction Recovery)
“5 years+
In recovery”
“Recovering People”
“Normal “Long Term Recovery”
People” “Better than well”
Potential
“A grateful
“Early addict/alcoholic”
Recovery” “Model citizens”
Time
18. Desistance rates
CSAT (2009): 58% of life-
course dependent users of
substances will achieve
lasting recovery
Welsh workers‟ estimate:
7%
19. Time spent (in minutes) in last drug working
session (Best et al, 2009)
How time is spent UK treatment activity
Clients seen typically
between 1-2 times per
10.6
month
13.7
10 minutes on
psychosocial interventions
Karpusheff et al (2012):
10.6
11.7 Sandwell – once every
4.4 weeks for 31 minutes
Wisely et al (2011):
Case Management
Therapeutic Activity
Links to other services
Other
Salford – 30 minutes
monthly
Best et al (in press)
21. Differences in reported quality of life as a function of
outcomes achieved
18
16
14 13.4060 13.4458
13.2955
12.9478
12
10
8
6
4
2
0
5-26 weeks 27-52 weeks 1-3 years 3+ years
.00 1.00 2.00 3.00 Linear (2.00)
22. Is the „treatment system‟ good enough?
„Careless Society‟ – John McKnight
“The professional problem” – the iatrogenic and
self-serving agenda of professionals
“Increasingly, professionals are claiming the
power to decide whether their „help‟ is effective.
The important, valued, and evaluated outcome
of services is the professional‟s assessment of
their own efficacy. The client is viewed as a
deficient person, unable to know whether he has
been helped” (McKnight, 1995, p.50)
23. The ultimate aim of
professionalisation
We are the solution to your problem
We know what problem you have
You cant understand the problem or the
solution
Only we can decide whether the solution has
dealt with your problem
24. The value of chronic illness
“A person with a perilous and extended illness (a
health consumer) contributes significantly to our
economic growth by using large amounts of the
commodities produced by our health system.
Indeed, a very ill person disabled for a
considerable amount of time could cause
production of much more medical dollar value
through their illness than the value of their own
production were they healthy”
(McKnight, 1995, p.162)
25. The consequence of
professionalisation
1984 study by Community Services Society of
New York
Approximately $7,000 per capita of public
and private money is allocated to the low
income population of that city
37% of this money reaches low income
people in cash income
Nearly two-thirds is consumed by those who
service the poor
27. Social networks and quality of life
Holt-Lunstad et al (2010): meta-analysis:
“individuals with adequate social relationships
have a 50% greater likelihood of survival
compared to those with poor or insufficient
social relationships” (p.14)
Participation in groups is associated with less
psychological distress (Ellaway and
MacIntyre, 2007)
Volunteering is associated with reduced mortality
(Ayalon, 2008) and higher levels of reported
wellbeing (Morrow-Howell et al, 2003)
28. Helliwell and Barrington-Leigh (2012):
the benefits of social capital
Based on the Canadian General Social Survey
Strronger social networks are associated with
higher life satisfaction
But this is mediated by more frequent use of
the social support network, when there is
greater trust of people you live and work with
and when people feel a sense of belonging in
their communities
29. Study of workers in the field in
recovery from heroin addiction
(n=108)
Why did they stop? Tired of lifestyle plus a
trigger event – physical, psychological or
family based
Why did they stay stopped? Other people
Moving away from using networks
Finding supportive non-using recovery
networks
Best et al (2008)
30. Litt et al – “Changing network support
for drinking” (2009)
186 participants randomised to network support (NS) or
case management (CM)
Network support condition resulted in better outcomes than
case management
“The addition of just one abstinent person to a social
network increased the probability of abstinence for
the next year by 27%” (p230)
Social networks can be changed by an intervention that is
specifically designed to do so
McKnight and Block (2010): Stronger support networks
linked to better access to community resources and to
better health
31. Framingham Heart Study
Christakis and Fowler
A person‟s odds of becoming obese increased by
57% if they had a friend who became obese, with a
lower risk rate for friends of friends, lower again at
three degrees of separation
No discernible effect at further levels of remove
Smoking cessation by a spouse decreased a
person‟s chances of smoking by 67%, while smoking
cessation by a friend decreased the chances by
36%. The average risk of smoking at one degree of
separation (i.e., smoking by a friend) was 61%
higher, 29% higher at two degrees of separation
and 11% higher at three degrees of separation.
32. Line = a relationship between two people
more embedded = central
less embedded = periphery
Node = a person
“embedded”: the degree to which a person is connected within a network
33. • Contagion:
what flows across ties
(germs, money, violence, fashions,
organs, happiness, obesity, etc.)
• Connection:
who is connected to whom
(ties to family, friends, co-workers, etc.)
• Homophily:
the tendency to associate
with people who resemble
ourselves
(“love of being alike”)
35. • 66% of Americans are overweight or obese
• From 1990 to 2000, the percentage of obese people in the USA increased from
21% to 33%
Green Node: nonobese
Yellow Node= obese (size of circle is proportional to
BMI)
1975 1990
39. VISIBILITY OR NOT – STUDY OF
HIV POSITIVE GAY MEN
Cole et al (1996): study of the long-term effects of
hiding their sexual identity: associated with higher
rates of cancer and infectious disease
Jones et al (2012): Those who hide a potentially
stigmatising condition more vulnerable to the
negative views that mainstream society holds
because it limits their ability to develop a collective
coping response
Molero et al (2011): while there were
risks, disclosing their HIV status allowed individuals
to develop a sense of shared identification with
others in the same situation
40. VISIBILITY OR NOT
Beals et al (2009): Among gay men and
lesbians: voluntarily mentioning one‟s sexual
orientation to others when the opportunity
presented itself was associated with lower
levels of depression and higher levels of self-
esteem
This relationship was mediated by perceived
levels of social support
41. VISIBILITY OR NOT - ABI
Molero et al (2011): Concealment of injury
may be an important strategy for protecting
oneself from negative outcomes
However, respondents who were more willing
to disclose their injury to others reported
higher levels of self-esteem and life
satisfaction
43. Social and mental health benefits of
choir singing for disadvantaged adults
Reclink community choir engagement at
baseline, 6 and 12 months -21 IPA interviews
PERSONAL IMPACT: positive emotions, emotion
regulation, spiritual impact, identity
SOCIAL IMPACT: connectedness with choir, with
audience, with community
FUNCTIONAL IMPACT: health, employment
capacity, routine and structure
Dingle, Brander, Ballantyne & Baker (2012)
44. Dingle et al (2012):
Personal, social and functional
growth
45. Douglas (2012): intensive social
support for individuals with
Traumatic Brain Injury (2012)
Programme over 6 months –
sports, arts, cooking
Naturalistic split into completers, partial
engagers and non-participants
Sustained group better at 6 months in
Social integration
Mental health
Quality of life
Reduced depression
46. Recovery studies in Birmingham and
Glasgow (Best et al, 2011a; Best et
al, 2011b)
More time spent with other people in recovery
More time in the last week spent:
Childcare
Engaging in community groups
Volunteering
Education or training
Employment
47. Comparison of US data with 113
participants recruited from Melbourne
NEW YORK MELBOURNE
Age 44.1 yrs 43.2 yrs
Duration of abstinence 45 months 72 months
Lifetime MH diagnosis 38.5% 63.2%
HIV+ 26.7% 1.0%
HCV 31.2% 41.3%
Primary heroin 21.8% 41.6%
Primary crack 59.2% 0.9%
Current 12-step 79.7% 69.3%
Current social club/group 13.7% 40.7%
Employed FT 48.4% 58.3%
Currently in education 21.7% 31.9%
49. Recovery-oriented treatment in
Victoria
‘Recovery’ is individually defined
Strengths and hope based
Connects people with other services they need
Recognises and builds support pathway beyond treatment
Treatment delivery that respects and supports individual
goals
Involves and engages people in planning and decision
making
Recognises, encourages and supports family/carer
involvement
Language, attitudes and behaviours that are respectful
of, and hopeful for, the client’s goals
50. New models of care – 6 core
service types
Education, I Assessmen Counselling Withdrawal Pharmaco- Residential
nformation, t Care and • Day • Residential therapy Treatment
Intake Recovery programs • Home based • GPs and • Residential
Co- • CCCCs • Outpatient pharmacists rehabilitation
• Telephone ordination • Therapeutic • Rural • SPS • Therapeutic
helplines 4Cs • CHAD • PROW communities
• Web-based • CCCCs • Parenting • Short-stay
• WADS
tools • ADSA support rehab
• Regional • ACSO COATS • Family
intake • Koori A&D counselling
• PAMS Workers
• DACAS • Outreach
• AMS • Peer support
• ABI/DD • Post Resi
workers
• ABI/DD
• MORS
52. Groshkova et al (in press)
Drug and Alcohol Review
50 item strengths based scale
10 dimensions
Capacity to differentiate between in and out
of treatment populations
Use as a care planning tool
Equally relevant to those in and out of
treatment
53. Background
The recovery movement is about some key principles:
Empowerment of the service user
Involvement of their family, and developing community
and peer supports
Dynamism that helps clients move forwards with their lives
and that the focus is not all about the substance
Recovery is a journey in which treatment plays an
important role in engaging and motivating clients
54. Aim of the model
To create a ready reckoner that will assess the
five key stages of treatment recovery journeys:
1. Motivation to recover
2. Engagement in the treatment and recovery
process
3. Development of personal recovery capital
4. Development of social recovery capital
5. Engagement in recovery communities
55. CEST - MOTIVATION
There are 2 measures of motivation
1.) Readiness to change
2.) Desire for help
• Participants reported a mean total motivation score of 12 (on
a scale of 0-14)
• For the overall scale that is recalculated to a score out of 20 –
and so mean = 17.1/20
56. CEST – TREATMENT ENGAGEMENT
There are 3 measures of treatment engagement
1.) Counsellor rapport
2.) Treatment Satisfaction
3.) Treatment Engagement
• Participants reported a mean total treatment
engagement score of 12.3 (on a scale of 0-32)
• Again this is recoded to a score out of 20 = 7.7.
57. ARC -Personal Recovery Capital
Personal recovery capital is made up of the following 5
subscales:
- 1.) Psychological health
- 2.) Physical health
- 3.) Risk taking behaviour
- 4.) Coping & life functioning
- 5.) Recovery experience
• Participants reported a mean total personal strengths score of
13.8 (on a scale of 0-25).
• When recoded to a score out of 20, this gives a mean
score of 11.0
58. ARC – Social & Lifestyle Recovery
Capital
Social & lifestyle recovery capital is made up of the following 5
subscales:
- 1.) Substance use & sobriety
- 2.) Citizenship
- 3.) Social support
- 4.) Meaningful activity
- 5.) Housing & safety
• Participants reported a mean total social & lifestyle strengths score
of 12.7 (on a scale of 0-25), recoded to a mean score of 10.2 .
59. RECOVERY
GROUP
PHASE
CAPITAL
5
3
4
3
TREATMENT 2 SOCIAL
ENGAGEMENT RECOVERY
5 5
4 1 4 CAPITAL
3 3
2 2
1 1
1 1
PHASE
2 2
3 3
1
4 4
5 5
TREATMENT
MOTIVATION
PERSONAL
RECOVERY
PHASE 2
CAPITAL
60. THANK YOU
Associate Professor David Best
davidb@turningpoint.org.au
David.best@monash.edu
