Maike Klein and David Best
It is now generally accepted that addiction treatment and recovery operate according to fundamentally different models and processes, to the extent that it is reasonable to regard them as having different paradigms – underlying principles, processes, models and so on! Addiction treatment is (generally) focused on the individual, based on the assumption of reducing harm and reinstating health, is clinic-based, and professionally run and predicated on a model of expert knowledge as well as professional delivery. In contrast, recovery from addiction has been recognized as intrinsically social, as emphasising individual choice and self-determination, as focussing on building strengths and as a lifelong journey of growth and giving back, with a main emphasis on facilitating active engagement with community resources and attempts to develop these.
For that reason, we are rightly suspicious about translating the tools of treatment to recovery, whether medical-assisted, talking therapy, or alternative models of supports. Recovery deserves and needs its own set of knowledge principles (epistemologically) and its own underpinning science and evidence base. In some instances, there is merit to merging the traditional approach to addiction recovery, as long as bespoke recovery models can be generated through appropriate recovery evidence. An example of this, which we are going to explore, is around recovery care planning.
What is recovery care planning and how does it work?
Recovery care planning is a process during which recovery service providers support the person’s application of the learning from their recovery journey outside of the recovery service. Traditionally, this has involved the recovery navigator and person in recovery discussing recovery goals (with an emphasis on absence of addiction symptoms) and steps to achieve these.
As part of our work on developing the REC-CAP (Cano et al, 2107; Hard et al, 2022; Best et al, 2023), we have used an online system called ARMS (the Advanced Recovery Management System) where the person in recovery completes their assessment and is immediately provided with a score profile. What the REC-CAP also does, however, is then ‘pivot’ from that profile to suggested templates for creating ‘recovery goals’ that allows the recovery navigator (generally a peer mentor) to guide the selection of goals based on the assessment and to utilise two sets of resources to achieve those goals:
1. Strengths the person has that have been identified during the assessment
2. Local community resources that the organisation has relationships with who can help in this area
In this regard, the REC-CAP transitions from being an assessment of recovery capital, to being the basis for an intervention which can support the growth of recovery capital. This is a crucial part of the REC-CAP as an active model of building recovery strengths, based on their measurement and mapping. These goals are then broken down into actions that can be split into SMART-defined activities that are then recorded on the ARMS system to be discussed at quarterly reviews. As such, REC-CAP can facilitate strength-based and recovery-oriented care planning in a way that is uniquely tailored to the goals and aims of the individual. Practically, this involves close collaboration between recovery staff and people in recovery to create, review, and refine a care plan that addresses barriers, strengths, and goals for recovery within different areas of life. An example of using REC-CAP as framework for care planning is shown in Figures 1 and 2 below, based on a technique known as node-link mapping, a way of visualising the process that is consistent with a recovery approach built on shared understanding and partnership.
Figure 1 shows the initial goal-setting process, during which recovery staff and people in recovery agree on a variety of recovery goals. In addition, both parties also discuss specific actions to take as well as the person’s available resources and strengths for achieving these goals. Lastly, both parties discuss and track what barriers there are to achieving these goals, and how these can be overcome (e.g., solutions). Goal maps like these will be co-constructed and may involve more than one goal as well as development in any, or all, of these mapped areas. As illustrated in the example given, the idea is to be clear about what strengths and resources are available and how they can be deployed to meet a significant goal.
Figure 1. Example of a Goal Setting Map
Throughout the care planning process, these goal maps will be continuously reviewed. The overall care planning process, including the information that is being tracked and reviewed, will then be cumulatively mapped, as shown in Figure 2. In this map, the summary of identified strengths are outlined in the top three boxes as the resources to draw upon to meet the personalised and individualised goals that are specified in the lower row in the middle. The bottom row also reminds both parties about the challenges they face in terms of recovery barriers and unmet needs around treatment and support. This is the basic building block for recovery care planning in which all the strengths listed across the top row become the resources available to overcome the barriers and achieve the goals outlined below:
Figure 2. Example of Care Planning Map
What have we done in this space to date?
In Virginia, in the USA, this approach is now well-established; we have trialed this approach with two communities in partnership with the Virginia Association of Recovery Residences (VARR) where a cohort of recovery navigators provided us with their feedback on how this type of recovery care planning is working. There will be a research paper (and blog) soon outlining our work in this area.
What is our project and plan for testing this manual?
Our project will employ a mixed-method design to pilot the REC-CAP measure as a recovery-specific intervention for care planning and evaluate its potential for best practice. The project will involve collaboration with partner sites in both, the USA and UK, and generate data through focus group interviews, goal map audits, and questionnaires.
Our plan is as follows:
Develop and facilitate one initial training workshop at each of the collaborator sites to introduce the concept and process of the REC-CAP manual as a care planning intervention (REC-CAP-CP)
Offer regular supervision meetings (online) with recovery navigator participants to discuss feedback, progress, and answer any questions over the course of the project
Recruit participants who are willing to provide feedback about the use of the REC-CAP during their care planning engagement
Assess client engagement, satisfaction, and effectiveness with the REC-CAP-CP through feedback forms on the process and through audits of the resulting recovery care plans
Conduct separate focus group interviews with both participant groups (recovery navigators and with people in recovery they are working with), to hear about their experiences and perspectives on the REC-CAP-CP intervention
Disseminate the generated understanding to practitioners, commissioners, and policymakers
In conclusion, there remains a need to further develop care planning activities in line with a more holistic view of recovery, and to further support the notion that recovery is practiced and maintained in the community, and not in a clinical treatment setting. The project outlined above will afford us with an opportunity to enhance the ways in which treatment settings generate recovery outcome data (in line with a holistic, wellness perspective of recovery) and share this knowledge with stakeholders who have the ability to create change.
We will work closely with trusted recovery providers to enhance and develop these tools to ensure that the REC-CAP model is engaging and effective in supporting recovery pathways and goals.