Recovery, Rehabilitation, and Social Reintegration

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Looking for a referral to, or more information about, mental health or substance use treatment services? The federal Substance Abuse and Mental Health Services Administration has a free, confidential National Helpline at 1-800-662-HELP (4357). "SAMHSA’s National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information."
SAMHSA's website also offers a free, confidential Behavioral Health Treatment Services Locator.

1. What Recovery Means

"The WHO Lexicon of alcohol and drug terms (1994, p. 55) defines ‘recovery’ as:

"Maintenance of abstinence from alcohol and/or other drug use by any means. The term is particularly associated with mutual-help groups, and in Alcoholics Anonymous (AA) and other twelve-step groups refers to the process of attaining and maintaining sobriety. Since recovery is viewed as a lifelong process, an AA member is always viewed internally as a ‘recovering’ alcoholic, although ‘recovered’ alcoholic may be used as a description to the outside world;

"whereas ‘rehabilitation’ is defined as:

"The process by which an individual with a substance use disorder achieves an optimal state of health, psychological functioning, and social well-being. Rehabilitation follows the initial phase of treatment (which may involve detoxification and medical and psychiatric treatment) […] There is an expectation of social reintegration into the wider community. (emphasis added)"

"According to these definitions there is a clear overlap between social reintegration and rehabilitation, whereby social reintegration forms an aspect of, but is not synonymous with, rehabilitation. Recovery, according to the WHO glossary, appears to be relatively unrelated to the term. However, since the publication of the WHO glossary in 1994, the understanding of the term ‘recovery’ has developed further and today it is much closer to the meaning of the term ‘rehabilitation’ as quoted above. As Best and colleagues (2010, p. 275) note: ‘The target of recovery is about quality of life rather than abstinence, although abstinence may be a long-term goal for clients.’"

European Monitoring Centre for Drugs and Drug Addiction. EMCDDA Insights Series No 13: Social reintegration and employment: evidence and interventions for drug users in treatment. Luxembourg: Publications Office of the European Union, 2012, p. 31.

2. Importance of Social Reintegration for Recovery

"Drug use often develops from being occasional to problematic: ties with close family members and non-using friends are gradually severed, while school and professional performance can be seriously affected and may come to a premature end. As a consequence, the normal process of socialisation, the integration of an individual from adolescence to adulthood as an independent, autonomous member of society, is jeopardised and this often leads to a gradual exclusion into the margins of society. However, this is a two-sided process. At the same time, society is marginalising problem drug users, making their access to education, employment and other social support even more difficult. Also, one should not forget that, in many cases, social exclusion already precedes drug use. Drug use often then exacerbates the already difficult life conditions of excluded individuals, making integration efforts a real challenge for the individual and for those providing support. This aspect is particularly relevant during the current period of economic difficulties in Europe, with high levels of unemployment among young European citizens and their gradual impoverishment.

"In order to protect problem drug users or recovering users from further social exclusion and to support them in their integration efforts, it is crucial that we provide individuals with opportunities and tools that are efficient, adequate and acceptable both for them and for their social environment."

European Monitoring Centre for Drugs and Drug Addiction. EMCDDA Insights Series No 13: Social reintegration and employment: evidence and interventions for drug users in treatment. Luxembourg: Publications Office of the European Union, 2012, p. 7.

3. Importance of Social Reintegration for Recovery

"Research shows that drug treatment contact impacts positively on clients’ physical and psychological health, reduces drug use and criminal activity, reduces injection and lowers the risk of non-fatal overdose (e.g. Gossop et al., 2000a,b; Prendergast et al., 2002; Stewart et al., 2002; WHO, 2009). Thus, accessing and adhering to drug treatment is a significant step towards recovery from drug dependence, but additional social support is often required. Indeed, drug use affects many spheres of life, including family and relationships, housing, education and employment, and it is also associated with social and economic exclusion. This can undermine the gains people have made while in treatment. It is therefore increasingly recognised that, in order to improve treatment outcomes, prevent relapse and ensure successful integration into society, drug dependence must not be treated in isolation; instead, the wider context in which drug use and recovery take place must also be considered and addressed (UNODC, 2008; Neale and Kemp, 2010). The United Nations Office on Drugs and Crime (2008a, p. 18) describes this approach as ‘sustained recovery management’, as a positive alternative to the current common approach of ‘admit, treat, and discharge’, often resulting in revolving-door cycles of high dropout rates, post-treatment relapse and readmission rates.

"Consequently, the aim of social reintegration measures is to prevent or reverse the social exclusion of current and former drug users (including those who are already socially excluded and those who are at risk of social exclusion), but also to facilitate the recovery process and help sustain the outcomes achieved during treatment."

European Monitoring Centre for Drugs and Drug Addiction. EMCDDA Insights Series No 13: Social reintegration and employment: evidence and interventions for drug users in treatment. Luxembourg: Publications Office of the European Union, 2012, p. 22.

4. Drug Dependence Treatment and Sustained Recovery Management

"Drug dependence treatment—within an acute care, symptoms-focused paradigm—has fallen short of properly addressing the complex, multifactorial nature of drug dependence that often follows the course of a relapsing and remitting chronic disease. There is disillusionment with the 'admit, treat, and discharge', revolving door cycles of high dropout rates, post-treatment relapse, and readmission rates. As a response to this situation there is a shift towards a more long term perspective of sustained recovery management (White 2007; White and Davidson, 2006) that is much broader and holistic in scope (Bradstreet, 2004) than linear recovery models."

TreatNet. Drug Dependence Treatment: Sustained Recovery Management. Vienna, Austria: United Nations Office on Drugs and Crime, 2008, p. 14.

5. A Sustained Recovery Management Approach to Substance Dependence Treatment

"The recognition of drug dependence as a multi-factorial health disorder, which often follows the course of a relapsing and remitting chronic disease, has spurred calls to shift the focus of drug dependence treatment from acute care to an approach of sustained recovery management in the community. Sustained recovery management applies many of the central components of recovery capital and the Sustainable Livelihoods framework. Service wise, a sustained recovery management approach offers the following:

"• Uses a strengths-based approach, considering the resources available in the clients life;
"• Takes into account the main areas of life/the eight domains of recovery capital (and their potentially compounding interrelationships) that can support rehabilitation and social reintegration for drug dependent persons;
"• Integrates a broader range of drug dependence rehabilitation and social reintegration support services, to strengthen human, vocational, and social capital necessary for a healthy, stable and meaningful life.
"• Uses broad, family- and community-focused, strengths-based, continual assessment processes;
"• Implements early and assertive engagement by service professionals;
"• Develops client- and family-generated recovery plans;
"• Includes assertive management of co-occurring disorders and challenges to recovery;
"• Uses peer-based models of recovery support and community resource development and mobilization;
"• Shifts the centre of service activity from the institutional environment to the client/family’s natural environment in the community;
"• Puts emphasis on sustained monitoring, recovery coaching, assertive development and linkages to the community services for recovery support and, as needed, early re-intervention;
"• Focuses on long-term evaluation of the effects of service combinations and sequences.
"• Establishes a sustainable health care partnership between service providers and clients;
"• Aims at easy access to services by shifting their location from remote institutions to the client/family’s natural environment in the community;
"• Emphasizes the importance of policy change and advocacy to reduce social stigma attached to drug dependence, and to promote recovery supportive policies and programmes (White, Boyle, and Loveland, 2002);

"Building social capital is a visible, central element of sustained recovery management. It encompasses four of the eight domains of recovery capital in Figure III above, namely, family and social supports; peer-based support; community integration and cultural renewal; and healthy environments."

TreatNet. Drug Dependence Treatment: Sustained Recovery Management. Vienna, Austria: United Nations Office on Drugs and Crime, 2008, p. 18-19.

6. Recovery Capital

"In this context, “recovery capital“ is the sum of personal and social resources at one’s disposal for addressing drug dependence and, chiefly, bolstering one’s capacity and opportunities for recovery” (Cloud and Granfield, 2001).

"Recovery capital can be used as a tool for drug dependence treatment professionals practitioners, to identify the strengths of their clients, support them in building up and maintaining a sustainable livelihood, while looking holistically at all domains of life. This approach meets individuals 'where they are' and supports them along the continuum of treatment, rehabilitation and social reintegration.

"Building recovery capital is a strengths-based approach. It involves identifying and building upon the client’s major personal and social assets, which may have been developed earlier in life or are newly acquired. These assets can support treatment engagement and enhance motivation for treatment, the treatment process and ongoing recovery from drug dependence problems.

"The eight domains of recovery capital identified by the Treatnet working group (shown in Figure III) are:
"1) Physical and mental health;
"2) Family, social supports, and leisure activities;
"3) Safe housing and healthy environments;
"4) Peer-based support;
"5) Employment and resolution of legal issues;
"6) Vocational skills and educational development;
"7) Community integration and cultural support; and
"8) (Re)discovering meaning and purpose in life.

"A lack of such assets could hamper the recovery process and desired outcomes."

TreatNet. Drug Dependence Treatment: Sustained Recovery Management. Vienna, Austria: United Nations Office on Drugs and Crime, 2008, p. 17.

7. Treatment Effectiveness at Reducing Levels of Offending

"Overall, lower levels of acquisitive offending and high-cost offending were recorded at follow-up. Among those who continued to offend, improvements in offending behaviour at follow-up, in terms of a decrease in its volume and/ or the costs associated with it, were observed. Crack users, injecting users, users with high SDS [Severity of Dependence Scores] scores, and those with previous treatment experience were more likely to offend than others at any point. However, neither referral source nor the type of treatment modalities received, were significantly associated with the level of acquisitive offending at any point (within the adjusted model)."

Andrew Jones, et al., "Research Report 24: The Drug Treatment Outcomes Research Study (DTORS): Final Outcomes Report" (London, England: UK Government, Home Office Ministry, Research, Development & Statistics Directorate, December 2009), p. 10.

8. Effectiveness of Treatment on Employment and Social Reintegration

"The Drug Treatment Outcomes Research Study (DTORS) was one example of European research with encouraging results regarding employment (Jones et al., 2009). This study investigated drug use, health and psychosocial outcomes in 1 796 English drug users attending a range of different types of treatment service. Follow-up interviews were conducted between 3 and 13 months after baseline (soon after initial treatment entry). Regardless of the type of treatment received or drug use outcomes, employment levels increased from 9 % at baseline to 16 % at follow-up. This was accompanied by a corresponding increase in the amount of legitimate income earned per week. The proportion reporting being unemployed but actively looking for work decreased slightly from 27 % to 24 %, reflecting the increase in employment and a 5 percentage point increase in those reporting being unable to work (because of long-term sickness or disability). The proportion of participants classed as unemployed and not looking for work also fell from 24 % to 11 %. Treatment attendance was also associated with changes in housing status; the proportion staying in stable accommodation increased from 60 % to 77 % at follow-up. It should be noted that the findings of this study were weakened by use of a non-experimental design, failure to separate outcomes according to client type and treatment modality, and insufficient detail on the nature of the employment obtained."

European Monitoring Centre for Drugs and Drug Addiction, EMCDDA Insights Series No 13, "Social reintegration and employment: evidence and interventions for drug users in treatment" (Luxembourg: Publications Office of the European Union, 2012), ISBN: 978-92-9168-557-8, doi: 10.2810/72023, p. 67.