Recovery Management: Presentation Guidelines

1. Recovery Management: Presentation Guidelines Bill White bwhite@chestnut.org www.williamwhitepapers.com

2. Presentation Goal Enhance each participant’s abilities to prepare and deliver presentations on RM & ROSC via conference keynotes & workshops, inservice trainings, and meeting presentations with key individuals and groups.

3. Learning Objectives: Participants will be able to • Define & distinguish recovery management (RM) and recovery-oriented systems of care (ROSC) • Identify and discuss 8 areas of RM-related changes in service practice • Discuss tasks and tools for each of the 3 stages of effective RM presentations

4. Personal Perspective • Work in addictions field since 1969 • 1998-2003: Behavioral Health Recovery Management Project • 2002-2008: presentation & consultations on RM & P-BRSS • 2005-present ATTC/Philadelphia DBH/MRS monograph series • Gratitude to leadership team members

5. Your Personal Perspective Each of you who present on this subject will need to build your own credentials and reputations on this subject. • No substitute for preparation: You must become a serious student of this subject to avoid “flavor of the month” perception • I will suggest resources as we proceed that will help with this process.

6. Topical Resources • RM/ROSC Monograph Series, particularly the “science monograph” (2008) • RM/ROSC Papers at www.williamwhitepapers.com • Book: Kelly, J. & White, W. (Late 2010) Addiction recovery management: Theory, science and practice. New York: Springer Science. • Video of presentations from Philadelphia & Atlanta & PowerPoint Slides

7. Resources to Enhance Presentation Skills • Training of Trainer opportunities • The Training Life: Full text available at www.williamwhitepapers.com • Menu of presentation slides • Availability of email/phone consultation with resource team, White, Achara, Laudet, etc.

8. Conceptual & Language Clarity “Recovery management” (RM) is a philosophical framework for organizing addiction treatment and recovery support services across the stages of pre-recovery identification and engagement, recovery initiation and stabilization, long-term recovery maintenance, and quality of life enhancement for individuals and families affected by severe substance use disorders.

9. Recovery Management & Stages of Recovery • Pre-recovery identification and engagement (recovery priming) • Recovery initiation and stabilization • Transition to successful recovery maintenance • Enhancement of quality of personal/family life in long-term recovery

10. Conceptual & Language Clarity Recovery-oriented systems of care (ROSC) are networks of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The system in ROSC is not a treatment agency but a macro level organization of a community, a state or a nation.

11. RM & ROSC Focus Today • My focus will be on how you as individuals and as teams can serve as presenters within a variety of educational venues within your respective regions to introduce the concept and practices of RM. • Dr. Achara will focus on how you can serve as facilitators and resource brokers for groups interested or involved in ROSC-related systems transformation processes.

12. Stages of Effective RM/ROSC Presentations Are Like other Effective Presentations 1. Pre-presentation Planning (It’s all about the details—setting, audience, message refinement) 2. Clear Presentation Stages --Opening --Middle --End 3. Post-presentation Follow-up (information & TA)

13. Stage One: Opening • Spans 30-60 minutes prior to presentation through first 10% of presentation time • Multiple tasks to be achieved in narrow window of time • RM/ROSC-related material can be threatening to multiple parties: Opening tasks essential to enhance receptiveness

14. Tasks and Tools for Presentation Opening 1. Resolve problems with presentation environment 2. Early audience contact, assessment & welcoming (refine message & diminish distance) 3. Engage * Initial presentation of self—warmth, humility, respect, curiosity, confidence * Speaker identification with audience

15. Tasks and Tools for Presentation Opening 4. Equalize presenter-participant power --evaluate degree of power discrepancy --increase or decrease your power --control the introduction --gage formality based on organizational/cultural context --early participant involvement

16. Tasks and Tools for Presentation Opening 5. Reduce resistance by acknowledging achievements of modern addiction treatment (See forthcoming slides as sample) --Given such achievements, why does treatment need to be “transformed”? 6. Create clear expectations via goals and learning objectives: Let audience know you will answer the why question using treatment systems performance data and their own experience (where time & format allows the latter)

17. Tasks and Tools for Presentation Opening 7. Honor the participants contributions and ideas via praise & gifts (resources, e.g., handouts, monographs, links, etc.) 8. Create sense of historical & personal urgency via your own commitment & energy

18. Achievements of Modern Treatment Include Elimination of Below

19. Achievements of Modern Treatment Include (To name a few): • Replicable, community-based treatment modalities • Federal, state, local, private partnership to fund addiction treatment and ancillary support industries, e.g., research, training, etc. • Accessibility: From less than 50 to more than 13,000 U.S. specialty treatment programs

20. Achievements of Modern Treatment Include: • Professionalization of addiction medicine & addiction counseling • Systems of early intervention, EAP, SAP, SBIRT • Screening/assessment/diagnostic tools • Continuum of care • Millions of lives touched and transformed Background Source: Slaying the Dragon

21. Core Presentation Tasks Core of Presentation Must Answer 7 Questions • Why does addiction treatment need to be transformed? • What changes in frontline service practices occur in the shift to recovery management? • What changes in administrative, regulatory, funding practices can be anticipated as part of an RM/ROSC transformation process?

22. Core Presentation Tasks 4. How will this process of systems transformation be achieved? 5. Who will be involved in systems transformation (and how will it affect my role)? 6. When will this process begin and how long will it take? 7. What obstacles should we anticipate?

23. Core Presentation: Tools Craft a presentation using a mix of the following based on the audience characteristics and the time available • Findings from scientific research • Treatment systems performance data (localize where possible) • Video & Internet Resources • Self-disclosure / Stories • Structured discussions and learning exercises

24. Critical Content Areas I will focus in this first presentation on how you can best answer: • Why does addiction treatment need to be transformed? • What changes in frontline service practices occur in the shift to RM?

25. Impetus for Change 1. Cultural and political awakening of individuals/families in recovery * Growth/diversification of mutual aid * New recovery advocacy movement * New recovery support institutions Tell this story in pictures Resources: Let’s Go Make Some History www:facesandvoicesofrecovery.org

28. Impetus for Change 2. Frustration of frontline addiction professionals 3. Addiction science, particularly research on addiction/recovery careers, treatment outcome studies & treatment systems performance data

29. Impetus for Change 4. Addiction treatment payors 5. Need to counter growing cultural pessimism about treatment, e.g., effects of celebrity rehab recycling

30. RM & ROSC Part of Shift in Emphasis within 3 overlapping Governing Constructs • Pathology Paradigm: Knowledge drawn from study of the etiology and epidemiology of substance use disorders • Intervention Paradigm: Knowledge drawn from study of social and clinical interventions into severe AOD problems • Recovery Paradigm: Knowledge drawn from the study of long-term addiction recovery

31. Limitations of Acute Care Approach to Addiction Treatment • Modern treatment has focused on an acute care model of addiction treatment • Define AC Model • Extol what the AC Model can achieve: biopsychosocial stabilization more effectively, more safely for more people than has ever been achieved in history • “Treatment Works”, BUT Recovery initiation does not assure recovery maintenance for people with high problem severity / low recovery capital—antibiotics analogy

32. Limitations of Acute Care Approach to Addiction Treatment • Discovery that addiction shares many characteristics with other chronic medical disorders (McLellan, et al, 2000) • Growing interest in: How would we treat addiction if we really believed that addiction was a chronic disorder?”, e.g., how models of “disease management” in primary health care might be adapted to long-term management of addiction

33. AC. RM & key recovery performance measures Each of you will need to personalize and localize presentation of this material, but following 8 elements are essential • Review current AC model performance limitations • Outline current & future directions of RM-models of care

34. 8 Key Performance Arenas Linked to Long-term Recovery Outcomes • Attraction, access & early engagement • Screening, assessment & placement • Composition of the service team • Service relationship • Service dose, scope & quality

35. Key Performance Arenas Linked to Long-term Recovery Outcomes • Locus of service delivery • Assertive linkage to communities of recovery • Post-treatment monitoring, support and early re-intervention NOTE: There are others but these 8 are most critical

36. 1. Attraction, Access & Early Engagement AC Limitations • 10% & 25% data; late stage and under coercion; waiting list drop-out data; attrition data (more than 50% will not complete) RM Directions • Assertive community education & outreach • Assertive waiting list management • Lowered threshold of engagement; rethinking motivation; institutional outreach • Changes in administrative discharge policies

37. 2. Screening, Assessment & Placement AC assessment is categorical, pathology-focused, professionally-driven, an intake function & focused on individual; placement based on problem severity. RM assessment is global, strengths-based, client focused (rapid transition to recovery plans), continual and encompasses the individual, family and recovery environment; recovery capital factored into placement decisions.

38. 3. Composition of the Service Team AC model uses disease rhetoric but few medical personnel; recovery rhetoric but decreasing involvement of recovering people. RM expands role of medical (including primary care physicians) and other allied professionals, recovering people (P-BRSS) and culturally indigenous healers. Also emphasizes reinvestment in volunteer and alumni programs.

39. 4. Service relationship Acute Care: Dominator model; emphasis on professional authority; great power discrepancy; role of client is one of compliance. Recovery Management: Sustained recovery partnership (long-term consultation) model; emphasis on prolonged continuity of contact; client as co-leader; philosophy of choice; greater use of personal/professional self; contrasting ethical guidelines.

40. 5. Service Dose, Scope & Quality AC model has become ever briefer, narrower via reimbursable services & continues to incorporate methods lacking scientific support. RM model emphasis on importance of dose (NIDA principles—90 days), role of ancillary services and weeding out practices that are not linked to recovery outcomes or that may produce inadvertent injury.

41. 6. Locus of Service Delivery AC model locus is the institution: How do we get the individual into treatment—get them from their world to our world? * Problem of transfer of learning RM model emphasizes the ecology of long-term recovery: “How do we nest recovery in the natural environment of this individual or create an alternative recovery-conducive environment?” * Healing forest metaphor (Coyhis) * Concept of “community recovery”

42. 7. Assertive linkage to communities of recovery AC Model: Passive linkage, low affiliation and high early attrition, single pathway model of recovery RM model: Assertive linkage, multiple pathway model of recovery, linkage beyond recovery mutual aid groups; active relationship with local service committees, involved in recovery community resource development

43. 8. Post-treatment Monitoring, Support and, if needed, Early Re-intervention • 50-80-90 rule: More than 50% of clients discharged from Tx will return to some use in the next year—80% of those will do so in first 90 days after discharge. • 15-25 rule: The stability point of recovery (risk of future lifetime relapse drops below 15%) isn’t reached until 4-5 years for alcohol dependence; 25% of opioid dependent persons who achieve five years of abstinence will later resume narcotic addiction.

44. 8. Post-treatment Monitoring, Support and, if needed, Early Re-intervention 25-35% of clients who complete addiction treatment will be re-admitted to treatment within one year, 50% within 2-5 years (Hubbard, et al, 1989; Simpson, et al, 2002). An Acute Revolving Door: Of those admitted to the U.S. public treatment system in 2003, 64% were re-entering treatment--23% accessing treatment the 2nd time, 22% for the 3rd or 4th, and 19% for 5 or more times (OAS/SAMHSA, 2005).

45. 8. AC Model: “Aftercare” as an Afterthought Post-discharge continuing care can enhance recovery outcomes (Johnson & Herringer, 1993; Godley, et al, 2001; Dennis, et al, 2003). But only 1 in 5 (McKay, 2001) to 1 in 10 (OAS, SAMHSA, 2005) adult clients receive such care (McKay, 2001) and only 36% of adolescents receive any continuing care (Godley,et al, 2001)

46. 8. RM Model: Assertive Approaches to Continuing Care • Post-treatment monitoring & support (recovery checkups) • Stage-appropriate recovery education & coaching • Assertive/continued linkage to recovery resources • Early re-intervention & re-linkage to Tx and recovery support resources • Recovery community building

47. Closing of Presentation: Summation • Outlined 5 sources of impetus for shift to a model of sustained recovery management • Outlined 8 areas of service practice that significantly change in the transition from AC to RM model • RM/ROSC do not eliminate AC model, but wrap the AC model in RM technologies for those with severe AOD problems and low recovery capital • Add ROSC points from Dr. Achara’s presentation on RM/ROSC transformation process.

48. Closing of Presentation: Express a Sense of Historical Urgency It will take years to transform addiction treatment from an exclusively AC model of intervention to a RM model of sustained recovery support. The future of addiction treatment and recovery will hinge on well how we are able to achieve this task.

49. Closing of Presentation: Make It Personal & Open It Up • The personal/professional destinies of some of you in this room are linked to leadership in this emerging movement. For some of you, your whole lives have prepared your for this unique moment in the field’s history. (Extend invitation for involvement.) • Again expression your gratitude for the invitation to present & open for further questions, comments and personalization of material

50. Concluding Note on Preparation and Presentation Process Parallel Process: What you want to convey to your audience is the very essence of the transformation experience, e.g., focus on engagement, tolerance, respect, personal and system strengths, partnership, honesty (transparency), and commitment to continuity of support).