Background and UK context
In the UK, there is an emerging movement to support and sustain community-based recovery, primarily through the work of the Dame Carol Black Review (Part II), followed up in the most recent drug strategy, “From Harm to Hope” (HM Government, 2021). This has resulted from the growth of the College of Lived Experience Recovery Organisations – a collective that has been created to develop an evidence base for community recovery, to promote and champion innovation and, crucially, to develop a set of quality standards through which recovery organisations can grow and build.
CLERO was tasked (in the recommendations of the Carol Black report) with developing quality standards for Lived Experience Recovery Organisations, helping to move us some way along the road to the ‘parity of esteem’ which CLERO set as a goal – to be treated as both integral and on a par with all of the other components of the prevention, treatment and recovery ‘system of care’. What this blog will attempt to explore is what that means in practice and where LEROs can contribute to a fully integrated and recovery-oriented model of care.
So what does a recovery-oriented system of care look like?
In 2005, the Centre for Substance Abuse Treatment (CSAT) convened a National Summit on Recovery where participants agreed on 17 principles for a recovery-oriented system of care (ROSC) which were:
- Person-centred
- Inclusive of family and other ally involvement
- Individualised and comprehensive services across the lifespan
- Systems anchored in the community
- Continuity of care
- Partnership-consultant relationships
- Strengths-based
- Culturally responsive
- Responsiveness to personal belief systems
- Commitment to peer recovery support services
- Inclusion of the voices of lived experience and their families
- Integrated services
- System-wide training and education
- Ongoing monitoring and outreach
- Outcomes driven
- Research-based
- Adequately and flexibly funded
(Sheedy and Whitter, 2009)
Following the summit, a formal definition of a recovery-oriented system was agreed as “networks of organisations, agencies and community members that coordinate a wide spectrum of services to prevent, intervene and treat substance use problems and disorders (Sheedy and Whitter, 2009, p.9).
In an earlier article, O’Connell and colleagues (2005) had argued that a recovery-oriented environment (for both mental health and addiction recovery) should:
- Encourage individuality
- Use a language of hope and possibility
- Support risk-taking even when failure is a possibility
- Actively involve service users, family members and other natural supports in the development and implementation of services and programmes
- Encourage user participation in advocacy activities
- Help develop connections with communities
- Help people develop valued social roles, interests and hobbies and other meaningful activities
Both of these lists of bullet points offer significant principles to guide the development and shaping of recovery-oriented systems but what I intend to argue is that the role of Lived Experience Recovery Organisations is about translating those principles into actions that have systemic impact.
So what implications does this have for LEROs?
In the UK at least, one of the primary roles of the LERO is around advocacy and championing the voice of lived experience, community engagement and connection, and helping to build active recovery participation in service delivery.
Broadly this can be understood in terms of a number of broad activities:
- Creating a visible and accessible recovery community that provides a diverse range of activities that meet the needs of multiple groups and populations. In other words, while mutual aid groups may well be at the heart of what is offered, the LERO has to act as a hub for multiple pathways and adopt an almost agnostic approach to any one philosophy or model of recovery
- Engage in outreach activities to engage with two groups – those involved in specialist treatment services and those not in contact. Thus, in the UK, the work that The Well Communities does in a prisons and through Accident and Emergency departments in hospital and the coffee bike activities of Recovery Connections in Middlesbrough are classic examples of ‘outreach’, where visible and engaging recovery champions make links to vulnerable groups in the community some of whom may be in touch with treatment but not all will be. Linked to this is building genuine and equal partnerships with treatment services. The second challenge in this area is around creating bridges to professional organisations – mental health services, employment and housing, and other specialisms that will be needed by people in recovery, but crucially also with specialist addiction services
- Contributing to the wellbeing of the community and challenging exclusion and stigma: This is the area where LEROs can have the greatest impact in terms of building bridges to volunteering (such as the brilliant work done by DATUS in their See Change programme in Birmingham with conservation projects such as replacing the bins in the local country park), and building community capital through visible and successful partnerships with different community groups, and with other excluded and vulnerable populations. This is also where the role of contagion of hope is so important – to family members, to neighbourhoods and to the whole community where the power of recovery can be genuinely transformative for communities.
- The last point, which I think remains a huge challenge, at least in the UK, is around cultural diversity. While there are some incredible beacons of hope, such as the wonderful BAC-IN in Nottingham, and its inspirational leader, Sohan Sahota, there is a danger that LEROs can become too focused on white, working-class men. For the UK, I think this is around the stage of development and there is emerging evidence that LEROs can play a central and integral role in engaging with diverse groups and communities and celebrating inclusion and engagement of a range of marginalised groups through the celebration of diversity and the championing of an umbrella model of ‘multiple pathways from multiple origins’.
But it is also crucial to acknowledge (and perhaps for commissioners to fund) the prevention and early intervention work that LEROs do in preventing lapses and relapses, and a return to crime. Their visibility and accessibility in communities means that can attract and engage those who are not ready for treatment as well as those who have left or dropped out, and this is a crucial safety net for communities and an intrinsic part of a recovery-oriented system of care. The Birmingham LERO, DATUS, refer to their work in this area as ‘reciprocal altruism’ to refer to the benefits their clients derive from an improved environment, while building new skills and new networks, and challenging stereotyped and stigmatising views of people in recovery.
Conclusion: The challenge and possibility for integrated services
There are a number of ROSC principles from the CSAT summit that constitute the heart of what a LERO could do within UK commissioning systems but also have potential implications elsewhere (including the US Recovery Community Organisation model).
They are:
- Systems anchored in the community
- Continuity of care
- Partnership-consultant relationships
- Strengths-based
- Culturally responsive
- Responsiveness to personal belief systems
- Commitment to peer recovery support services
- Inclusion of the voices of lived experience and their families
- Integrated services
- System-wide training and education
- Ongoing monitoring and outreach
The traditional idea that LEROs are a reactive provider of ‘aftercare’ for those completing treatment has been exploded as a myth in the UK and elsewhere.
The work in primary and acute medical care, in prisons and other areas of justice, and in community outreach suggests that their role is as much ‘pre-care’ as ‘aftercare’, notwithstanding the fact that for many, LERO support will be all they need. In other words, LEROs can be a one-stop shop.
They have a critical role in providing training, education and support to professionals and the general community, and offering pathways to education and employment. Many are involved in recovery housing, and this is something that needs to be adopted from the US model to a much greater extent. In Michigan, for instance, many of the recovery residences also provide recovery hubs (Recovery Community Centres) that not only offer meaningful activities and social connections to their residents, but are active bridges to the community and are open to anyone from that community.
In my previous blog, I spoke of the role of LEROs in engaging those returning from residential treatment (whether they complete it or not), but it is crucial to recognise that LEROs should be commissioned to be the bridges between specialist addiction services and from them to other professional groups, to communities and families and to active participation in communities. We will only have real Recovery Oriented Systems of Care if LEROs are seen as the golden thread that runs through prevention, treatment and recovery and as the fabric for community engagement and meaningful integration.
References
O’Connell, M., Tondora, J., Croog, G., Evans, A., & Davidson, L. (2005). From rhetoric to routine: Assessing perceptions of recovery-oriented practices in a state mental health and addiction system. Psychiatric Rehabilitation Journal, 28(4), 378–386.
Sheedy C. K., and Whitter M., Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know From the Research? HHS Publication No. (SMA) 09-4439. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2009.